CONTRIBUTORS TO VOLUME II. 
BELFIELD, WILLIAM T., M.D.; 
BEVAN, ARTHUR DEAN, M. D.; 
BLAKE, CLARENCE J., M. D.; 
BRADFORD, EDWARD H., M.D.; 
BULL, CHARLES STEDMAN, M. D.; 
DELAVAN, D. BRYSON, M.D.; 
DENNIS, FREDERIC S., M. D.; 
ETHERIDGE, JAMES H., M. D.; 
EVE, DUNCAN, M. D.; 
GERSTER, ARPAD G., M.D.; 
KELSEY, CHARLES B., M. D.; 
LOVETT, ROBERT W., M.D.; 
MATAS, RUDOLPH, M.D.; 
PARK, ROSWELL, M. D. ; 
PARKER, CHARLES B., M. D.; 
RICHARDSON, MAURICE H., M. D.; 
SOUCHON, EDMOND, M. D. A 
Treatise on Surgery 
BY 
AMERICAN AUTHORS. 
FOR STUDENTS AND PRACTITIONERS OF SURGERY 
AND MEDICINE. 
EDITED BY 
ROSWELL A.M., M.D., 
Professor of the Principles and Practice of Surgery and of Clinical Surgery in the 
Medical Department of the University of Buffalo, Buffalo, New York; Member 
of the Congress of German Surgeons; Fellow of the American Surgical 
Association; Ex-President Medical Society of the State of New 
York; Surgeon to the Buffalo General Hospital, etc. 
VOLUME II. 
SPECIAL OR REGIONAL SURGERY. 
WITH 451 ENGRAVINGS AND 17 FULL-PAGE PLATES 
IN COLORS AND MONOCHROME. 
LEA BROTHERS & GO., 
PHILADELPHIA ANI) NEW YORK 
1896. Entered according to Act of Congress in the year 1896, by 
LEA BROTHERS & CO., 
in the Office of the Librarian of Congress, at Washington. All rights reserved. 
WESTCOTT &. THOMSON, 
ELECTROTYPERS, PHILADA. 
PRESS OF 
WILLIAM J. DORNAN, PHILADA. PREFACE TO VOLUME II. 
On behalf of his fellow-collaborators the Editor takes this occasion 
to thank the surgeons and surgical teachers of America for the cordial 
reception so quickly extended to the first volume of the work, and to 
express the hope that the second and concluding volume may be simi- 
larly approved, both from the didactic and practical standpoints. 
If it be possible to judge from the written expressions already re- 
ceived from the most prominent teachers of Surgery, the work seems 
likely to fulfil one of its chief purposes—namely, the presentation of 
a thoroughly modern text-book reflecting the methods of teaching de- 
veloped by large experience. 
Practitioners of surgery, it is hoped, will find it equally suited to 
their needs, as every effort has been made to afford all necessary guid- 
ance in the principles as well as in every practical detail of surgical 
science and art. 
The illustrations, which are largely original, have been chosen with 
critical care, and each of the profuse series will be found to elucidate 
important matters and to supplement the text most valuably. 
It is no small task to gather a comprehensive and authoritative 
expression of. modern surgical knowledge. How far this effort has 
succeeded it remains for the surgical public to determine, but the 
Editor can at least say that he submits with confidence these volumes, 
* 
embodying as they do the most earnest work of the eminent gentle- 
men whose information is a credit and honor to the position of America 
in the surgical world. The Editor also wishes to renew here his ex- 
pressions of obligation to the gentlemen who have so kindly assisted 
him, as mentioned in the Preface to the First Volume. 
ROSWELL PARK. 
Buffalo, October, 1896. CONTRIBUTORS TO VOLUME II. 
WILLIAM T. BELFIELD, M. D., 
Professor of Bacteriology and Lecturer on Surgery, Bush Medical College, 
Chicago; Professor of Genito-urinary and Venereal Diseases, Chicago Poly- 
clinic, Chicago. 
ARTHUR DEAN SEVAN, M. D., 
Professor of Anatomy, Rush Medical College, Chicago ; Professor of Surgery, 
Women’s Medical School, Northwestern University, Chicago ; Surgeon to the 
Presbyterian, St. Luke’s, and St. Elizabeth’s Hospitals, Chicago. 
CLARENCE J. BLAKE, M. D., 
Professor of Otology, Medical School of Harvard University, Boston ; Aural 
Surgeon to the Massachusetts Charitable Eye and Ear Infirmary, Boston. 
EDWARD H. BRADFORD, M. D , 
Assistant Professor of Orthopaedic Surgery, Medical School of Harvard Uni- 
versity, Boston; Surgeon to the Children’s Hospital, Boston. 
CHARLES STEDMAN BULL, A.M., M.D., 
Professor of Ophthalmology, Medical Department, New York University, New 
York; Surgeon to the New York Eye Infirmary; Consulting Ophthalmic 
Surgeon to St. Luke’s, Presbyterian, and St. Mary’s Hospitals, New York. 
D. BRYSON DELAVAN, A. B., M. D., 
Chief of Clinic, Diseases of Throat, etc., College of Physicians and Surgeons, New 
York; Professor of Laryngology and Rhinology, New York Polyclinic; Con- 
sulting Laryngologist to the New York Cancer Hospital, the Hospital for Rup- 
tured and Crippled, and the Macdonough Hospital, New York ; Ex-President 
of the American Larvngological Association, etc. 
FREDERIC S. DENNIS, M. D., M. R. C. S., Eng. 
Professor of the Principles and Practice of Surgery, Bellevue Hospital Medical, 
New York; Attending Surgeon to Bellevue and St. Vincent’s Hospitals; Con- 
sulting Surgeon to the Montefiore Home and the Harlem Hospital, New York ; 
Member of the German Congress of Surgeons. 
7 8 
CONTRIBUTORS TO VOLUME II. 
JAMES H. ETHERIDGE, A. M., M. IX, 
Professor of Obstetrics and Gynecology, Rush Medical College, Chicago; Pro- 
fessor of Gynecology, Chicago Polyclinic, Chicago ; Gynecologist to the Pres- 
byterian and Polyclinic Hospitals; Consulting Gynecologist to the St. Joseph 
Hospital, Chicago. 
DUNCAN EVE, A. M., M. D., 
Professor of Surgery and Clinical Surgery, Medical Department of Vanderbilt 
University, Nashville, Tennessee. 
ARPAD G. GERSTER, M. D., Ch. I)., O. M., Vienna. 
Visiting Surgeon to the Mt. Sinai and the German Hospitals, New York ; Ex- 
President of the New York Surgical Society. 
CHARLES B. KELSEY, M. I)., 
Professor of Abdominal and Rectal Surgery, New York Post-Graduate Medical 
School and Hospital, New York. 
ROBERT W. LOVETT, M. D., 
Surgeon to the Infants’ Hospital and to the Out-patients, Boston City Hospital, 
Boston; Assistant Surgeon to the Children’s Hospital, Boston. 
RUDOLPH MATAS, M. D., 
Professor of General and Clinical Surgery, Medical Department, Tulane Uni- 
versity of*Louisiana, New Orleans; Visiting Surgeon to the Charity Hospital 
of New Orleans, etc. 
ROSWELL PARK, A. M., M. D., 
Professor of Principles and Practice of Surgery and Clinical Surgery in the Medi- 
cal Department of the University of Buffalo ; Surgeon to the Buffalo General 
Hospital, etc., Buffalo, N. Y. 
CHARLES B. PARKER, M. D., M. R. C. S., Eng. 
Professor of Clinical Surgery in the Cleveland College of Physicians and Surgeons, 
Cleveland, Ohio. 
MAURICE IT. RICHARDSON, A.B., M. D., 
Assistant Professor of Clinical Surgery, Medical School of Harvard University, 
Boston ; Visiting Surgeon, Massachusetts General Hospital, Boston. 
EDMOND SOUCHON, M. D., 
Professor of Anatomy and Clinical Surgery, Medical Department, Tulane Univer- 
sity of Louisiana, New Orleans; Visiting Surgeon, Charity Hospital, New 
Orleans. CONTENTS OF VOLUME II. 
CHAPTER I. 
PAGE 
SURGICAL DISEASES AND INJURIES OF THE HEAD 17 
By Roswell Park, M. D. 
CHAPTER II. 
SURGICAL DISEASES AND INJURIES OF THE SPINE 86 
By Edward H. Bradford, M. D. 
CHAPTER III. 
SURGICAL DISEASES AND INJURIES OF THE HEART AND PERI- 
CARDIUM, WITH SURGERY OF THE LARGE BLOOD-VESSELS; 
LIGATIONS 126 
By Duncan Eve, M. D. 
CHAPTER IV. 
SURGICAL DISEASES AND INJURIES OF THE RESPIRATORY OR- 
GANS 158 
By D. Bryson Delavan, M. D. 
CHAPTER Y. 
SURGICAL DISEASES AND INJURIES OF THE FACE 202 
By Edmond Souchon, M. D. 
CHAPTER V. (continued). 
SURGICAL DISEASES AND INJURIES OF THE NECK 231 
By Edmond Souchon, M. D. 
CHAPTER YTI. 
SURGERY OF THE CHEST 257 
By Frederic S. Dennis, M. D. 
CHAPTER VII. 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, TONGUE, 
TEETH, AND JAWS 311 
By Arthur Dean Bevan, M.D. 
9 10 
CONTENTS. 
CHAPTER VIII. 
PAGE 
SURGERY OF TIIE ABDOMEN 339 
By Maurice H. Richardson, M. I)., assisted by Farrar 
Cobb, M. D. 
CHAPTER IX. 
HERNIA 407 
By Maurice H. Richardson, M. D. 
CHAPTER X. 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE 431 
By Charles B. Kelsey, M. D. 
CHAPTER XI. 
GENITO URINARY SURGERY 457 
By William T. Belfield, M. D. 
CHAPTER XII. 
CHANCROID OR VENEREAL ULCER 519 
By Roswell Park, M. D. 
CHAPTER XIII. 
SURGICAL DISEASES AND INJURIES OF THE FEMALE REPRO- 
DUCTIVE ORGANS 522 
By James II. Etheridge, M. D. 
CHAPTER XIV. 
SURGICAL DISEASES AND INJURIES OF THE BREAST 503 
By Charles B. Parker, M. I). 
CHAPTER XV. 
AMPUTATIONS 589 
By Rudolph Matas, M. D. 
% 
CHAPTER XVI. 
ORTHOPEDIC SURGERY 620 
By Robert W. Lovett, M. D. 
CHAPTER XVII. 
PLASTIC SURGERY 686 
By Arpad G. Gerster, M. D. CONTENTS. 
11 
CHAPTER XVIII. 
PAGE 
THE SURGICAL DISEASES AND INJURIES OF THE EYE AND 
ORBIT 701 
By Charles Stedman Bull, M. D. 
CHAPTER XIX. 
SURGICAL DISEASES AND INJURIES OF THE EAR 749 
By Clarence J. Blake, M. D. 
CHAPTER XX. 
ON SKIAGRAPHY, OR THE APPLICATION OF THE RONTGEN 
RAYS TO SURGERY 764 
By Roswell Park, M. D. SPECIAL OR REGIONAL SURGERY. 
CHAPTER 1. 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
Roswell Park, M. D. 
The Scalp. 
Erysipelas and cellulitis of the scalp are the result of the same 
infections and conditions as when met with in other regions, but are 
peculiarly prone to occur here because of the liability to infection from 
the hair with the material concealed in and upon the surface. They 
lead frequently to suppuration, in which case abscesses form that may 
extend inside the cranium, as into the frontal or other sinuses. These 
are common about the orbit and in the upper eyelid, and unless speedily 
incised may lead to gangrene. Multiple abscesses are also common. 
Disturbances of sight and hearing as sequels of these infections are 
occasionally met with. The principal danger from these purulent col- 
lections pertains to intracranial infection or general sepsis, usually of 
pysemic type. 
Carbuncles are frequent upon the back of the neck, though they seldom occur 
upon the scalp proper. Even small ones are rarely met here. Nevertheless, car- 
buncles have been known to extend from one ear around to the other. Occurring 
in this region, the infection is serious and prognosis is unfavorable. Met with 
here, they should be treated, as elsewhere, by free incision, with extirpation of all 
infected tissues. Their presence should always excite the suspicion of diabetes, 
alcoholism, or pronounced uric-acid diathesis ; for each of which, when recognized, 
appropriate medication should be adopted. 
Gangrene' of the scalp may result either from infection or injury. In badly- 
nourished children it may follow various skin eruptions. That type known as 
gangrenous emphysema may also be met with here. All forms of gangrene may 
be followed by necrosis of the underlying skull, especially when the periosteum is 
involved. Threatening gangrene should be treated by early excision of the sus- 
picious area, or at least by incision to relieve tension. Actual gangrene should 
lead to prompt extirpation of all infected tissues. 
The various ulcerations of the scalp which may result from Avounds, phlegmons, 
carbuncles, etc., as well as from the infectious granulomata—i. e. syphilitic and 
tubercular—or those of cancerous nature, differ only from other ulcerations else- 
where by the accident or limitation of their location. The most common ulcera- 
tions of non-traumatic origin are due to breaking down of neoplasms. The treat- 
ment for each of these does not require special mention here, having been already 
described in the other parts of this Avork. 
Gaseous Tumors of the Scalp.—The most common of these is ordi- 
nary emphysema, which may result from injury to the upper air-passages 
17 18 
INJURIES AND SURGICAL DISEASES OF THE IIEAI). 
or even involving the lower. Thus, fractures of the nasal bones or of 
the base of the skull may permit the distention of the subcutaneous 
cellular tissue by forcible inspiration of air. Emphysema of the seal]) 
may be a valuable diagnostic feature in certain instances. When con- 
nected with a wound it would best be enlarged in order to permit the 
escape of contained air. Otherwise, these puffy swellings usually dis- 
appear spontaneously by absorption of air into the veins. In cases of 
malignant or gangrenous emphysema, early and numerous incisions 
should be made, after which antiseptic solutions, etc. should be gener- 
ously resorted to. 
Pneumatocele.—A pneumatocele is a chronic gaseous tumor, being 
a cavity distended with air which has escaped from the cells of the 
underlying bone, bounded on the outside by the seal]), beneath by the 
cranium. They are met with about the mastoid or the frontal region. 
Not more than two dozen cases in all are on record. In consistency 
these tumors are elastic, while the escape of air upon pressure is some- 
times to be heard upon auscultation. Their explanation is almost 
always a defect of the inner wall of the mastoid cells, through which air 
may be forced from the pharynx through the middle ear by violent effort. 
Bony defects which might permit this condition are met with in a small 
percentage of craniums. 
The best results in the way of treatment have been achieved by 
puncture, with the injection of weak iodine solution. 
Syphilis of the Scalp.—The seal]) may be the site of syphilitic 
eruptions, ulcerations, or necroses. These differ in no respect from 
similar lesions elsewhere. In syphilitic disease of the bones there is 
greater ease of infection and breaking-down of the overlying skin 
because of their proximity. Gumma of the soft parts or of bone, and 
caries of the latter, will nearly always lead to superficial ulceration, 
which shall call for a combination of local surgical and general medical 
treatment. 
Tuberculosis of the Scalp.—This same may be said of tubercular 
lesions, which when superficial will, for the most part, assume the lupoid 
type, or when deep will be inseparable from other manifestations of 
tuberculosis of the flat bones. 
Tumors of the Scalp.—These may be divided into the congenital 
and the acquired, as well as into the benign and malignant. 
Of the congenital tumors, the dermoids are of most interest. In order to fully 
understand dermoids of the cranium we must remember that originally the dura 
and the skin were in contact, and that the cranial bones develop as an after-thought. 
This will explain the occurrence of dermoids either beneath or outside of the 
bone or their simultaneous appearance and possible connection. Many of the 
so-called atheromatous cysts or wens are really of dermoid origin. Those which 
are extracranial need only antiseptic incision or excision. It will often be enough 
to split such a cyst with a bistoury, after which each half of the sac can probably 
be easily detached from the bed in which it has lain. Should intracranial con- 
nection bg discovered, the bone-chisel and sharp spoon will be necessarily called 
into employment. Some of these dermoids perforate into the orbit, and may have 
to be followed into that location. 
All of the dermoids and cysts of the skull may require to be differentiated from 
meningoceles and prolapsus cerebri: in fact, one should always distrust a con- 
genital tumor about these regions, but particularly those near the middle line. 
The external tumors never alter in size during sleep, and can rarely, if ever, be 
pressed back within the cavity of the skull; which cannot be said of either of the I)rsCASKS OF THE BLOOD-VESSELS. 
19 
other conditions just mentioned. In case of doubt the exploring needle may be 
used. 
Cornu cutaneum is seen more often upon the scalp than elsewhere, its explana- 
tion being afforded in the chapter on Tumors in Volume I. It calls for complete 
excision, which, if thorough, will be sufficient. 
Of- the other tumors, benign or malignant, most varieties may be 
met with in this region. Subcutaneous collections of fat are not so 
common, nor are fibromata. Various bony growths may be met with, 
while in certain cases the signs of brain-pressure are to be explained 
only by their extension within the cranium. 
Malignant tumors are common about the scalp and the cranium ; they 
assume, however, no conventional appearance, and may be met with in 
any shape or form, those of the scalp alone occurring either as carcinoma 
or epithelioma from its epithelial elements, or as sarcoma from its meso- 
blastic elements. Tumors primary in the periosteum or bone must neces- 
sarily be of sarcomatous nature, while those of the type which perforate 
to the surface may be either sarcoma or possibly endothelioma. With 
regard to the general character of these growths enough has been already 
said in Volume I. Concerning their extirpation (for there is no other 
treatment than this), operations of varying degrees of severity may be 
called for. 
The superficial epithelioma should be, if possible, attacked before it has become 
adherent, in which case everything should be removed down to the underlying 
periosteum, after which a plastic operation will permit the repair of the defect, so 
that primary union of the whole surface may be secured. Any malignant growth 
which is adherent to the underlying cranial bone calls not only for removal of its 
own substance, but for that of the bone to which it is attached. To fail in this is 
to invite recurrence. This may necessitate more or less extensive osteoplastic 
resections of the bone, but the condition permits of no middle course. Very 
extensive resections of bone have been made with success, and need not be 
abstained from unless there be good reason to fear involvement of the dura or 
cortex. In this case the advantages and dangers must be carefully weighed before 
proceeding to operation. During operations on the bone great care should be 
taken, especially in certain regions, to avoid injury to the intracranial sinuses, 
although we have learned that these may be ligated and intervening portions 
removed—almost with impunity when necessary. But the wounding of the sinus 
by the point of an instrument or spicule of bone may lead to a most hazardous 
and annoying complication, and is to be prevented when possible. A small wound 
in a sinus may be plugged with gauze, which may remain for two or three days. 
There is always a possibility of air-embolism (see Chapter II. Vol. I.) when the 
sinuses are opened, since their walls do not easily collapse. Hemorrhage from the 
soft parts may be almost entirely controlled by the use of an elastic tourniquet 
stretched around the skull. Oozing veins in the diploe or in the bone may often 
be secured by pressing the tables of the skull together with bone-forceps, while at 
other times an antiseptic wax can be forced into the interstices of the bone and 
hemorrhage thus be checked. In certain cases where it seems impracticable to 
slide flaps and cover defects, the desired end may be obtained by skin-grafts after 
Thiersch’s method. 
Diseases of the Blood-vessels. 
Aneurisms and vascular tumors, especially the latter, are met with 
about the scalp. The form of aneurism most common is the so-called 
cirsoid, already described in Chapter XXXII. Vol. I. Single aneur- 
isms are, however, occasionally seen. These are, when upon the surface, 
always accessible, and are best completely extirpated. Cirsoid aneur- 
isms, when not too large, may be radically attacked, or, if excessive iu 20 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
size, may justify ligation of botli external (or even both common) caro- 
tids. The ordinary venous tumors, so-called mevi, etc., may either be 
excised or treated by electrolysis. Arterio-venous aneurisms, either 
external or connecting with the orbit or with an internal sinus, have 
been seen and described, but are so rare as not to warrant further men- 
tion here. Varicose conditions of the external veins are also occasion- 
ally seen. These may be due to mere weakness of venous walls, or may 
be the result of disease of the same or of obstruction to return circu- 
lation. 
A rare and specialized form of blood-tumor, met with only on or within the 
cranium, is the so-called hernial dilatation of the superior longitudinal sinus. It 
may present through openings in the bone; sometimes pressure upon it will cause 
vertigo and perhaps greater prominence of adjoining veins, even of the jugulars. 
Non-inflammatory Diseases and Congenital Conditions of 
the Skull. 
Incomplete formation of bone (aplasia cranii) is occasionally met 
with. The bone is a secondary formation in the skull, the dura and skin 
being originally in contact; consequently, this condition can be easily 
explained as a failure to develop bone where it is normally met with. 
These defects are most common in the frontal and temporal regions. 
The bone may fail also to develop to ordinary thickness, and may be 
Fig. 1. 
Craniotabes (rhachitis) (Bruns). 
found as thin as paper or ossifying only in certain directions. Super- 
numerary bones may also develop, apparently to take the place of those 
previously lacking. Aplasia may also be a unilateral defect, and con- 
tribute toward the formation of meningocele. Atrophy or anostosis— 
i. e. complete disappearance of cranial bones—is occasionally observed. 
It may be an interstitial or an eccentric process, and may happen at any DISEASES AND CONGENITAL CONDITIONS OF THE SKULL. 
21 
point or at several spots. Up to a certain extent it is the rule in the 
skulls of the aged, where the bones become reduced to the thinness of 
paper or may in certain places completely disappear. Senile atrophy, in 
Fig. 2. 
Leontiasis: skull of a Chinese woman (U. S. A. Museum, No. 10,620), 
other words, is a normal process, and is to be expected after the sixtieth 
year of life, its possibility being not forgotten when operations are under- 
taken upon the skulls of those advanced in years. Eccentric atrophy 
Fig. 3. 
Osteoma of skull (Mudd). 
may also occur from pressure of soft or hard tumors, among them the 
so-called Pacchionian bodies. It is stated also that increasing hydro- 
cephalus may produce an internal and eccentric anostosis. 22 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
Craniotabes or Cranial Rickets.—It is particularly in the skull 
Fig. 4. 
Same, seen from below. 
that the manifestations of rickets are most common, the bone becoming) 
unduly thick and the general shape being changed. Usually there is 
Fig. o. 
Syphilitic caries of cranium (Bruns). 
flattened vertex with delayed ossification, with an abnormally firm union SURGICAL AFFECTIONS OF THE CRANIAL BONES. 
23 
along the suture lines. In spite of these changes, the bone often becomes 
affected by pressure to such an extent that a rachitic or hydrocephalic 
child, confined in bed and moving little or not at all, will develop a skull 
showing the effect of such pressure. Many rachitic skulls show areas 
of atrophic thinning, dispersed irregularly, while the inner surface may 
show the markings of the convolutions impressed upon it by the softness 
of the bone. 
Leontiasis.—This has been already alluded to in Chapter XXXV. 
Vol. I. It refers to an abnormal thickening confined entirely to the 
skull and the facial bones. The trouble begins usually in the latter, but 
later involves the former. By the distortion of nature’s purpose a most 
peculiar appearance is given to the face and head. 
The pathology of the disease is absolutely unknown : the influence, 
once operative, continues to act until the bone becomes enormously thick- 
ened, and patients die either of brain-pressure or of inanition, the latter 
caused by encroachment upon the natural cavities of the face and cra- 
nium to such an extent that swallowing becomes impossible. The con- 
dition is absolutely hopeless. 
Surgical Affections of the Cranial Bones. 
The acute affections of bones have been already dealt with at con- 
siderable length in Chapter XXXAT. Vol. I., and but little needs to 
be said here in addition to statements therein contained. Acute 'peri- 
ostitis is, for the most part, due either to syphilis or to an infection follow- 
ing injury. In the latter case it proceeds from the margin of the wound, 
and may spread to a considerable distance. It is in some instances 
secondary to deeper infection extending from the middle ear, and then 
is found posteriorly to the ear and externally to the mastoid cells. Con- 
genital openings or defects of the sutures about the mastoid seem to 
have much to do with the travelling of infectious lesions in these 
localities. 
Acute osteomyelitis is due to essentially the same causes as those just 
discussed. In this case it is especially in the diploe that the principal 
ravages are met with. Unless very promptly recognized and relieved 
by surgical measures, this is exceedingly likely to lead to sepsis of the 
pysemic type and at a relatively early period, the venous arrangement 
of the diploe favoring such type of disease. 
Chronicperiostitis, or pericranitis, assumes rather the ossifying type, and leads 
to a formation of new bone—at least when not of tubercular character. The 
chronic tubercular lesions, however, are practically all connected with the ravages 
of the granulation-tissue which always marks the presence of tubercular disease 
in bone, so that these affections assume the clinical form of caries of the skull. 
Cold abscesses are frequent in connection therewith. The tendency of the disease 
is nearly always to spread, and it should be checked as early as recognized. In 
other words, the bone-cliisel and the sharp spoon are in these cases nearly always 
called into play, the consequence being that the dura is often exposed before the 
lesion is eradicated. This need occasion no alarm, but should give rise rather to 
a feeling of satisfaction at the thoroughness with which the surgical attack has 
been carried out. 
Necrosis of the skull is ordinarily the result, directly or indirectly, of 
injury, in which cases it is usually of the acute form, a fragment which 
has been too much separated from its surroundings to live, giving evi- 24 
INJURIES AN1) SURGICAL DISEASES OF THE HEAD. 
dence of early and easily recognizable death. This necrosis is, for the 
most part, confined to the external table. Necrosis of slow origin is 
due either to tuberculosis or syphilis, perhaps more often to the latter. 
Under a cold abscess of the scalp or subperiosteal abscess will often be 
found at least a small area of dead external table which needs complete 
removal. Necrosis has also been observed to follow severe burns of the 
scalp. 
In utero the head is surrounded by amniotic fluid and is well guarded 
against injury. Nevertheless, as the result of* penetrating wounds or of 
falls on the part of the mother such injuries do occasionally occur. 
Most of the cases of skull fracture reported as occurring before birtli 
have really occurred during delivery. Multiple fractures of the skull 
of either character have been observed. 
During the process of parturition there nearly always appears a 
tumor of the scalp in the new-born, commonly spoken of as the caput 
mccedaneum, at the point where pressure upon the head has been least. 
It usually disappears quickly after birth. It is due to a collection of 
Injuries to the Head Previous to and During Birth. 
Fig. 6. 
Fracture of right frontal bone in a new-born infant; fracture extending into orbit (Bruns) 
blood, partly an extravasation, as the result of compression or injury. 
It is composed also of (edematous soft tissues of the surface. If incised, 
blood-stained serum is poured out. When this fails to rapidly resorb 
during the first days of the infant’s existence, and especially if it fluctuate, 
it may be incised under antiseptic precautions and blood-clot be turned 
out or the necessary indication met in a judicious way. In rare cases it 
suppurates, by which is produced an acute abscess which naturally calls 
for prompt evacuation. 
A collection of fluid blood between the periosteum and the bone is 
known as the cephalhsematoma neonatorum, such a lesion occurring IMPORTANT POINTS IN SURGICAL ANATOMY OF THE SKULL. 
25 
on an average once in two hundred cases. It is met with most often 
over the fissures, and appears, at least in some eases, to be produced by 
the sliding of the bones. This collection also usually promptly disap- 
pears. In case of failure it may be aspirated or, if necessary, incised. 
Before resorting to any operative procedure it would be well to make a 
careful distinction between a possible meningocele or encephalocele as a 
congenital defect and cephalhsematoma as an accident of delivery. 
In the foetal head the cranial bones are easily displaced, and during delivery 
the size and shape of the head are materially altered, as must necessarily be the 
case in view of the tremendous pressure to which it is subjected in passing through 
the pelvis. It has been claimed that the dolichocephalic form of certain skulls is 
due to pressure exerted in the necessary direction during face presentation. Pre- 
mature alterations due to pressure may occasionally be met with, and may possi- 
bly give rise later to evidence of brain-pressure in the shape of epileptiform con- 
vulsions, etc. 
A depression in the skull of anew-born child which does not quickly 
right itself or yield to expanding influences from within should not be 
long allowed to go uncorrected, since disastrous lesions, for the most 
part of paralytic type, may result therefrom. In these days of aseptic 
surgery there is no reason why such operation as may be necessary to 
elevate a fragment or an entire bone should not be performed with full 
precaution. 
Important Points in the Surgical Anatomy of the Skull. 
It must be remembered, first of all, that the young and the aged have no dis- 
tinction of tables of the skull, but that the diploe which separates the two tables 
is an affair of middle age, develops slowly, and disappears after the same fashion— 
sometimes to such an extent as to leave the skull of almost paper-like thinness. In 
all operations, then, upon the young and the old, one must proceed with extreme 
caution, as expecting to find the skull quite thin. The lower limit of the squa- 
mous bone proper is the so-called masto-squamosal suture, and operations confined 
to the squamous plate alone are safe from injuring the sigmoid sinus on its inner 
side. The ridge at the posterior root of the zygoma indicates by its lower border 
the level of the mastoid antrum. A few lines above this, is the level of the base 
of the brain. The mastoid is present at birth and appears externally by the second 
year. Its antrum is present also at birth, though its air-cells do not develop until 
after puberty, their location being previously occupied by cancellous tissue. Most 
of these cells open into the antrum, a few directly into the tympanum. They are 
not always separated from the sigmoid sinus by bone. The partition between 
them is perforated by minute veins, forming an easy communication between the 
sinus and the antrum. Air escaping from the mastoid cells into the overlying 
tissue may cause emphysema from a basal fracture. In all operations upon the 
mastoid antrum one should keep to its outer side, and the higher and the more 
closely to the posterior zygomatic ridge he makes the first opening, the more sure 
is he to escape injuring the facial nerve. The groove for the sigmoid sinus extends 
to the jugular foramen from a point on the outside corresponding to the asterion. 
The lateral sinus may be indicated externally by a line from the superior border 
of the mastoid to the inion—i. e. from the asterion to the inion. 
The frontal sinuses are usually separated by a septum, which is often incom- 
plete or wanting. They are variable in size and outline, and do not develop until 
after the seventh year—in some cases to a relatively very large extent. The 
infundibulum, by which they empty into the nasal cavity, is often so small that 
when the lining membrane is involved it becomes closed, and retention with its 
accompanying symptoms—pain, tenderness, swelling, etc.—may ensue. Ulceration 
and erosion, however, may cause perforation internally to the supraorbital plates, 
so that pus may penetrate through the inner half of the orbit. 
Aside from its direct communication, the superior longitudinal sinus connects 
with the basal sinuses through the middle cerebral and the Sylvian veins, while 26 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
communications with the middle meningeal veins are quite free. Where the frontal 
and diploetic veins enter the longitudinal sinus there are frequently dilatations in 
which inarasmic thrombosis often originates. This sinus is also connected with 
the veins of the nasal septum, so that a septic phlebitis may be directly propagated 
from the nose. So much of the lateral sinus as is contained in the sigmoid groove 
is known as the sigmoid sinus, which connects directly with the exterior through 
the mastoid and the posterior condyloid veins. In sinus thrombosis this mastoid 
vein is usually likewise affected. One or more condyloid veins accompany the 
hypoglossal nerve through the anterior condyloid foramen, and may also serve for 
the propagation of infection or exit of pus. 
While septic particles may be carried—usually through the internal jugular— 
from any part of the lateral or sigmoid sinuses, they may also be carried by way 
of the other veins above mentioned or the occipital sinus; all of which empty 
directly into the subclavian without passing through the internal jugular. These 
sinuses are all rigid tubes, always open, while the veins are thin and flexible, their 
calibre constantly varying with inspiration and expiration. The sinuses contain 
no valves, and these are very rare in the cerebral veins. 
So far as the lymphatics are concerned, there is free and easy communication 
between the internal and external plexuses and nodes. Into the superficial nodes, 
along the external jugular, outside of the deep fascia, empty all the external lym- 
phatics of the head. Intracranial infection shows itself in swelling of the deep 
cervicals beneath the deep fascia. Lymphatics are abuudant in the dura, and 
pathogenic organisms, once housed within the dura, And it easily open to invasion. 
The potential interval between the dura and the arachnoid is termed the sub- 
dural space, where considerable effusion may occur without marked symptoms, 
owing to its easy diffusion, while blood poured out here may travel even to the 
lowest parts of the spine and cause death by pressure upon remote points. 
The arachnoid bridges over the convolutions and does not extend into the sulci. 
It is not vascular; at certain points it is adherent to the pia, at others does not 
touch it. The subarachnoid space is formed in the latter way, and within it most 
of the cerebro-spinal fluid is contained. This space is unevenly distributed over 
the brain surface, most prominent beneath the posterior two-thirds of the brain, 
where there is a wide interval between the arachnoid and the pia, extending for- 
ward over the medulla and pons and as far forward as the optic nerves. This space 
connects with the ventricles by the foramen of Magendie, as well as with the 
sheaths of the cranial nerves. When these nerves escape from the brain or cord 
they are covered by all three membranes, the layers being most distinct along the 
optic nerves. Fluid injected into the subdural space may pass along the spinal 
nerves as far as the limbs. It is essential to realize this in order to appreciate how 
extensive is the surface exposed in leptomeningitis. 
Internal hydrocephalus is often the result of closure of the foramen of 
Magendie. The cerebro-spinal fluid is rapidly reproduced after traumatic escape. 
External hydrocephalus, or accumulation in the subarachnoid space, is a condition 
frequently due to tubercular infection. 
The pia is the vascular coat of the brain, supplied with an extensive network 
of fine nerve-fibres derived from the sympathetic and the cranial nerves, having 
intimate relations with the brain, to such an extent that leptomeningitis and 
encephalitis are almost inseparable. The nerve-supply to the cerebral membranes 
explains the severe pain of meningitis. 
Injuries to the Soft Parts of the Cranium. 
In direct connection with what has just been stated above, it is well 
to emphasize that the venous communications between the exterior and 
interior of the cranium are numerous, and that the frequency of these 
anastomoses explains the ease with which extracranial infections are 
propagated within ; in other words, these explain the frequency of septic 
mischief in the brain from external injuries. 
Penetrating- and incised wounds are frequent about the head, their 
prognosis per se, as well as their proper treatment, varying but little 
from that of such wounds in other parts, so long as the skull proper 27 
INJURIES TO THE CRANIAL RONES. 
and its contents escape injury. Hemorrhage from scalp wounds may be 
free, even fatal. The most dangerous hemorrhages occur from the tem- 
poral vessels. Penetrating wounds are short, and the periosteum and 
underlying bone are usually also injured. Such small articles as blades 
of penknives, particles of dirt, etc. will often be found when the parts 
are carefully inspected, a measure never to be neglected. Contusions of 
the scalp and skull are spoken of as subcutaneous, subaponeurotic, or 
subperiosteal, and are most frequent in the frontal and lateral regions. 
Ecchymoses following them may be extensive and discoloration may 
spread over a large area. In traumatic haematomata resulting from 
various injuries incision should be early resorted to should blood-clot 
fail to resorb. 
Tkeatment.—In all head injuries the injured portion at least of the 
scalp should be shaved, by which cleanliness is promoted and examina- 
tion facilitated. Wounds should be treated upon the general prin- 
ciples enunciated in Volume I. Sutures are often called for, though 
when the edges of a scalp wound are ragged it would be better not to 
suture them until all the injured tissue has been cut away and the wound 
carefully disinfected. All the cephalh®matomata, no matter how exten- 
sive or deep, which lie outside of the bone are at all times amenable to 
incision when other treatment fails. Next to the immediate danger from 
failure to control hemorrhage, the greatest risk run by all of these cases 
is of failure to take proper antiseptic precautions in the beginning; and 
of all these injuries, one may say that the fate of a patient lies in large 
degree in the hands of the man who first treats him. Untold numbers 
of deaths have been the more or less remote consequences of infection 
proceeding from wounds improperly treated at first. 
Injuries to the Cranial Bones. 
All conceivable degrees of injury to the bones, from a trifling divis- 
ion of the periosteum down to most extensive denudation or mangling 
of the external table or the entire thickness of the bones, may be met 
with. These lesions may be spread over a large area or may be the 
result of penetrating wounds. In other words, we may have linear, 
penetrating, or large surface wounds with such injury to the scalp as 
perhaps to amount to a total loss of covering for the same. All of these, 
moreover, may be complicated by fractures of the bone at the point of 
injury, with or without brain lesions, or by other and more remote lesions. 
In regard to most of these, it may be said that non-penetrating inju- 
ries, when promptly and properly attended to, have, for the most part, 
a favorable prognosis. Every penetrating wound of the cranium is a 
condition justifying grave prognosis, on account of the great danger 
incurred of infection. Other features of these wounds, with more in 
regard to prognosis and treatment, will be given under the head of 
Compound Fractures of the Skull, etc., with which they are usually 
connected. 
It is necessary, however, to say in this place that penetrating wounds 
of the cranium are often received in a way which does not permit 
actual diagnosis, as, for instance, when received through the nose, the 
orbit, etc. Every wound whose history and appearance indicate that 28 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
penetration may have occurred should be, however, subjected to the most 
rigid scrutiny and care. Points of fencing foils, umbrella tips, etc. 
have been forced into the brain-cavity through the orbit and elsewhere, 
in a way which left little external evidence of the severity of the injury. 
Fractures of the Skull. 
Following the anatomists, and for general convenience, these are 
divided into fractures of the vertex, of the lateral region, and of the 
base, the former being the most frequent, since the vertex is the most 
exposed. A fracture in a given region may be confined to that locality 
or may radiate widely or extend nearly around the cranium. Of all the 
fractures of the bony skeleton, those of the skull constitute about 2 per 
cent. Fractures of the vertex are, for the most part, due to actual vio- 
lence, the force being often expended at the point of application or pro- 
ducing radiating fractures. Those which are limited to the neighbor- 
hood of the injury are spoken of as direct fractures, in distinction to 
Fig. 7. 
Multiple fractures with depression (Bruns). 
which we have indirect or radiating, often producing remarkable results. 
Fractures may vary between the simplest crack or fissure, accompanied by 
but trifling brain-symptoms and never recognized, to the most extensive 
comminution and destruction of cranial bones which can be imagined. 
Fissures are practically cracks in the skull, similar to those which 
may be seen in glass, and are not necessarily followed by the slightest 
displacement; nor is the entire thickness of the bone always involved, 
though in the majority of cases the internal table sustains more or less 
injury. Fissures are often spoken of as linear fractures. They may be 
straight or irregular, limited to one bone or involving several, single or 
multiple, and when radiating from a common centre are described as 
stellate. 
Splintered or comminuted fractures refer to the formation of 
numerous bony fragments which are often more or less loosened, some- 
times completely so, occasionally dovetailed together, and often driven 
in or depressed. Such fractures are direct. It is possible to have 
comminution without depression ; the latter makes it the more grave 
condition. FRACTURES OF THE SKULL. 
29 
Fractures with absolute loss of substance may be made by gunshot 
injuries or by any extensive splintering by a penetrating body. It is 
possible to have fracture of one table without that of the other, this being 
most often true of the external table. In isolated fractures of the inner 
table there is often dislodgement of small fragments which may injure 
the dura and possibly produce later epileptic or irritative disturbance. 
When the external table is chipped off the diploe is exposed, and this 
with its wonderfully tine venous communications opens up a wide area 
to infection and subsequent pyaemia. 
Gunshot fractures are always depressed and almost invariably com- 
minuted. The bullet of the modern army rifle possesses a great initial 
velocity, and the cranium struck by it will probably be disrupted into 
fragments, with instant death. The majority of gunshot fractures of 
the skull seen in ordinary civil practice are due to revolver or pistol 
bullets from weapons of the prevailing type of to-day. In these 
instances there will usually be penetration, perhaps with perforation of 
the skull, and the formation thus of one or of two compound fractures, the 
Fig. 8. 
wound of entrance being always comminuted and depressed, while frag- 
ments of bone may be scattered along the course of the bullet, which 
may also carry in infectious material from without, such as hair, parti- 
cles of hat, etc. 
Whatever may be the wisdom of operating in other cases where 
there is room for doubt as to the proper course, there never is uncer- 
tainty as to the proper treatment of gunshot wounds of the skull, which 
should be invariably subjected to operation. 
It will thus be seen that fractures of the skull may be simple or 
Gunshot fracture of skull (Helferich). 30 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
compound, or complicated with other injuries, or depressed, without any 
reference to whether they are simple fissures or more extensive injuries. 
On the other hand, depressed and comminuted fractures may occur with- 
out being compound in a surgical sense, and with each one of these 
injuries there may be accompanying disturbance of the brain of any 
degree of severity, from the mildest concussion or shock up to rapidly 
fatal compression. Any imaginable complication of these head injuries 
is not beyond the bounds of possibility. 
Fig. 9. 
Gunshot fracture of skull (Helferich). 
The essential features in explaining the mechanism of fractures of the vertex 
are the area involved and the violence of the impact. The skull is often surpris- 
ingly elastic, even in the oldest individuals, and fractures occur ordinarily when 
the natural limits of elasticity have been exceeded and bone-cohesion overcome. 
Children particularly suffer from depression without fracture, which formerly wyas 
never operated upon, but which is now regarded as calling for operation. On the 
other hand, certain skulls are abnormally fragile (see Fragility of the Bones, 
Chapter XXXV. Vol. I.), and, among the insane, may be found so porous and 
yielding as to be pressed out of shape without great difficulty. In injuries of 
slight extent it is enough that the skull be regarded as composed of an elas- 
tic substance, while for injuries produced by greater violence the skull is to be 
considered rather as a globe or arch possessed of high resistance and elasticity, 
whose shape will probably yield more or less before a fracture results. Much may 
be learned from such experiments as those of Felizet, who filled skulls with paraf- 
fin and dropped them from varying heights, and then divided the bone, to note in 
numerous instances that, although the bone had not been fractured, it had yielded 
at the point of impact to a degree producing a marked depression in the paraffin 
beneath. It is, then, certain from observation, as well as from a multitude of 
experiments, that after various injuries, especially to the top of the head, the 
shape of the skull is momentarily altered and its diameters affected. Many frac- FRACTURES OF THE SKULL. 
31 
tures, then, .are the result, as it were, of a bursting force, which may be shown by 
the fact that hair has been found included within closed fissures, as well as even 
the dura itself. Moreover, particles of bullets have been found within the skull 
without any visible opening through which they could have entered, showing that 
the bone has yielded under impact for a fraction of a second. It must also be 
remembered that in certain injuries to the head, as where a man is struck to the 
ground, there is injury at two points presumably nearly opposite. 
Fractures of the skull, especially of the vertex, possess surgical 
interest mainly as they are accompanied by more or less evidence of 
intracranial complications. So long as there is no evidence of hemor- 
rhage or laceration within, they are ordinarily regarded as a feature of 
the external wound with which they are usually found, and, unless there 
be comminution, depression, or some other good reason for operating, 
are covered over as the wound is closed, and are left to the natural pro- 
cess of repair by formation of minute callus or by the ossification of 
granulation-tissue. 
It is absolutely unfair to contrast the results of the surgery of to-day 
with those of the pre-antiseptic era. Rules then enforced are now 
entirely abrogated, and the methods of to-day would have made our 
surgical Ancestors protest most loudly. One respect in which we violate 
precedent is in our disregard, to-day, of the periosteum or pericranium. 
This is sacrificed without hesitation when found to be infected or torn 
or lacerated beyond capability of repair. A flap of scalp, it is known, 
will adhere as kindly to denuded bone as to periosteum, and we have 
even learned that skin-grafts can be applied and relied upon to adhere 
to this same bone—if not upon the first day, a little later when granu- 
lations have appeared. In the various plastic operations necessitated 
about the head we may also transplant flaps upon otherwise uncovered 
bone without the slightest hesitation. We have, furthermore, learned 
to treat fractures mainly in accordance with what we decide as to intra- 
cranial complications, or through what we can see either through the 
wound, if present, or through an opening intentionally made under anti- 
septic precautions for purposes of exploration. It is everywhere con- 
ceded to be better policy to remove fragments of bone whose vitality is 
uncertain, and to sacrifice ruthlessly any tissue injured or lacerated to 
such an extent that sloughing would probably follow, or so exposed as 
to have become necessarily infected. 
Diagnosis of Fractures of the Vertex.—In the absence of 
an open wound, and unless incision be made, this must often be con- 
jectural. In the presence of a wound diagnosis is usually easy, 
enlargement of the wound to any reasonable extent being perfectly 
legitimate for purposes of examination. In case of a small puncture 
with suspicion of fracture it will be usually better to enlarge it suf- 
ficiently to permit the introduction at least of the finger and of careful 
inspection. With the finger and the eye we seek to detect differences 
in level, depressions, fissures, etc. Mistakes often arise from the forma- 
tion of an exudate or a clot, by which a mere depression of the soft 
parts may be regarded as actual depression of the bone. Error occa- 
sionally arises from the existence of previous atrophy of the bone or any 
congenital defects in ossification of the skull; also in the skulls of syph- 
ilitic patients where disappearance of a gumma is often followed by 
absorption of the underlying bone. In every case of doubt it will be 32 
INJURIES ANI) SURGICAL DISEASES OF THE HEAD. 
wise to make exploratory incisions, of course under rigid aseptic precau- 
tions. These should not be made, however, unless the attendant is 
ready—i. e. has the facilities immediately at hand—for carrying out any 
further operative procedure that may be necessary, as elevation of frag- 
ments, removal of foreign bodies, etc. Areas of bloody infiltration often 
have abrupt margins which are calculated to easily deceive. In children, 
more especially, we often have a circumscribed bloody tumor which may 
contain cerebro-spinal fluid rather than pure blood. In some of these 
cases after exploration there will be found material resembling brain- 
matter, which, however, is not always such, although real brain-substance 
may escape, such escape necessarily 
implying rupture of the overlying 
membranes. Should it be noted that 
the fluid used for irrigating and 
cleansing such a wound begins to 
pulsate, it will almost always mean 
connection with the cranial cavity, 
and, obviously, fracture. A suture 
should not be mistaken for a line 
of fracture. This mistake is more 
easy when Wormian bones are pres- 
ent. One should not forget that 
blood may be wiped away from a 
suture line, but not from that indi- 
cating fracture. It is not often pos- 
sible to diagnose an isolated fracture 
of the inner table. It happened, 
however, once to Stromeycr to notice 
that so soon as an injured patient 
assumed the horizontal position he 
began to vomit, which nausea sub- 
sided when he was placed in the upright position. On autopsy it was 
found that there had occurred a depressed splintering of the inner table 
with perforation of the dura: less irritation was produced in the upright 
position than when the patient was lying down, which accounted for his 
vomiting when in the horizontal posture. When a comminution has 
been produced it is always of prognostic value to find an unbroken dura, 
since so long as its integrity is undisturbed the prognosis is better 
than when the reverse obtains. Prolapse of brain-substance is always a 
most serious complication. Escape of cerebro-spinal fluid is relatively 
rare. 
Treatment.—Treatment comprises attention to the local injury and 
the suitable dealing with the condition of the brain within when injured, 
fhe treatment of simple fractures is, for the most part, expectant. In 
the absence of indication for operation it should be exceedingly simple, 
and should consist of physiological rest, aseptic dressings, ice applications 
to the head, the administration of such laxatives, diuretics, antacids, etc. 
as may be necessary to favor free excretion and to guard against auto- 
intoxication. Whenever there is reason to suspect a depression, explora- 
tory incision at least should be made. Actual depression, whether the 
fracture be compound or not, calls always for operation, the opinions of 
Fig. 10. 
Depression of inner table (Bruns). FRACTUE.ES OF THE SKULL. 
33 
surgeons of past generations to the contrary notwithstanding. This 
course is justified by the numerous instances in which later consequences 
have been noted, such as traumatic epilepsy, insanity, etc. 
Compound injuries call always for operation of some character, in- 
cluding the removal of loosened splinters, the elevation of depressed 
bone, the removal of all foreign matter, the checking of hemor- 
rhage, the excision of bruised and lacerated tissue, and the proper 
closure of the wound, with or without drainage according to circum- 
stances. 
In many serious and lacerated cases it is inadvisable to close the 
wound with the view of attempting primary union. It is much better 
to pack it with gauze and temporarily close it with secondary sutures. 
All of these surgical measures should be seconded by efforts which every 
judicious surgeon will always put into practice—namely, physiological 
rest (quietude of the head, which may even be enforced by the posterior 
plaster-of-Paris splint to the head and neck), attention to the primes vice, 
the avoidance of transportation, the prevention of auto-intoxication, etc. 
The best judgment will often be called for in decision as to the amount 
of bone to be removed, the wisdom of opening the dura when not lace- 
rated, of examination of the brain with the exploring needle, the matter 
of drainage, the time during which it shall remain, etc. With reference 
to all these matters exact rules cannot be given, but every case must 
necessarily be decided upon its own merits. When drainage is made in 
recent cases it is usually sufficient to drain the scalp wound. Only in 
cases where there is probability of meningeal infection does it pay to 
deliberately attempt to drain the dural cavity. This is perhaps better 
done with gauze than with drainage-tubes. 
Skull-fractures where the injury is limited to a small area are now 
treated according to a bolder method than wras in vogue a number of 
years ago, especially in cases where depression is recognized. I believe 
thoroughly in caref ul and judicious operating in every case where distinct 
depression can be made out, as well as in every case wdiere indications 
point to injury of parts within the bone. The statistics of trephining 
in the pre-antiseptic era are valueless as arguments in this consideration. 
If done according to strict aseptic precautions and if good surgical judg- 
ment be used in every respect, the operation is per se almost devoid of 
mortality, and should not be regarded as a last resort, but rather in such 
cases as a first one. I have myself seen so many instances of later 
untoward consequences resulting from delay, which corroborate the expe- 
rience of others, that I wrould not be misunderstood in this matter. My 
advice might perhaps be summed up in the following words: Where 
there are no brain-symptoms and no skull-symptoms in fractures of the 
vertex leave the case alone; when either of these is present, especially the 
former, it will alivays be wise to operate. 
The question of how far interference, or how much of exploration, maybe per- 
mitted when the brain itself is injured is another to be decided only upon its merits. 
So far as gunshot injuries are concerned and the removal of missiles, it will prob- 
ably be the safest rule to follow that only foreign bodies which appear on or near 
the surface or which can be easily or definitely located call for removal. So far as 
other interference with the brain is concerned, it must be decided mainly on the 
brain-symptoms and upon the special localizing symptoms, all of which are yet to 
be considered. 34 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
In most of these fractures the violence is applied at some more or 
less distant point, and, by transmission through the arch-like structure 
of the skull, expends itself in Assuring or comminuting the base. The 
most frequent location of the indirect injury is upon the convexity. The 
mechanism of these fractures, indirect as most of them are, has been a 
vexed problem for many centuries, but has been cleared up mainly within 
the present century. Felizet has shown, for instance, how the handle of 
a hammer maybe forced into its head by striking it in either one of two 
different ways, and has compared the mechanism of basal fractures to 
this fact. The secret of basal fractures probably resides in the elas- 
ticity of the skull, which varies within wide limits in different individ- 
uals, and which breaks, as do the ribs and the pelvis, at points more or 
less distant from that at which the injury occurred. Were the skull 
Fractures of the Base of the Skull. 
Fig. 11. 
Fracture of base of skull (Bruns). 
everywhere equally thick and elastic, there would be much less variation 
in these fractures, but we know that lacerations frequently extend be- 
tween the most resistant parts; and when violence is applied upon the 
forehead we commonly find that the resulting fissure extends between 
the crista and the wings of the sphenoid upon the same side in its course 
toward the base : that when the lateral region of the skull is injured the 
fissure commonly extends between the sphenoidal wings and the occip- 
ital bone; and that when the occipital region receives the first injury the 
fracture lies usually between the pyramid and the occipital crests. The 
analogy between fractures of the skull and cracks made in nutshells 
(cocoanuts, etc.) when struck with a hammer is too self-evident to be lost PLATE I. 
Fractures of the Base of the Skull. Illustrative Lines of Fissure 
or Fracture are printed in Red. 35 
FRACTURES OF THE BASE OF THE SKULL. 
sight of. Many years since the French introduced the term f racture by 
contre-coup (counter-stroke)—a practical admission of the occurrence of 
fracture at a point more or less opposite to that struck. 
In 1884, Aran formulated the following conclusions, which will probably stand 
to-day undisputed: 
1. The great variety of indirect fractures of the base (by so-called contre- 
coup) are in reality fractures propagated from vertex to base—i. e. fractures by 
irradiation. 
2. Fractures reach the base from the vertex by the shortest anatomical route, 
traversing fissures in their course. 
3. There is a relation between the region of the skull first injured and the seat 
of the basal fractures. Accepting the anatomical division of the inner basal sur- 
face of the cranium into three fossae, it may be said that lines of fracture occupying 
either one of these fossae are likely to be produced by violence applied to the 
corresponding region of the vertex. 
There is, however, no certainty about these fractures, and to spend 
further time in this connection in studying these minutiae would be of 
little avail to the student. It will be enough to add, then, that exten- 
sive fissures of the vertex are almost always extended to the base of the 
skull, while the reverse is seldom true. There are doubtless also many 
cases in which a bursting force compromises the bone rather than mere 
radiation of unexpended violence; but so long as skulls conform to no 
fixed mathematical figures nor proportions, but are composed of bones 
varying in shape, density, and strength, ij: will be impossible to formu- 
late any laws which are comprehensive enough to be satisfactory. Frac- 
tures in the posterior fossh occurrfor the most part through violence 
applied posteriorly and frbm below. There is a ring-form of basal 
fracture produced mainly the-irftpact of the vertebral column, as 
when an individual falls upon 'tub weight of the body forcing 
the cranial base in upon the brain. Fractures of the anterior fossa may 
involve the roof of the orbit; even facial bones may participate in the 
injury. These considerations are not without importance, since if a 
patient presents symptoms of injury of the petrous bone, and if these 
be accompanied by injury to the lateral region of the skull, we are in 
position to make a diagnosis of fracture of the middle fossa. (Vide 
Plate I.) 
By all means, the majority of basal fractures are mere fissures which 
open and dose instantly upon their production—close so quickly, in fact, 
as scarcely even to include blood between the broken bony surfaces. 
Prognosis.—The majority of basal fractures arc fatal, cither because 
of injuries to the brain, or of hemorrhage or violence along the nerve- 
trunks, or from infection extending along the newly-opened paths. 
Other things being equal, the longer the fissure the greater the danger, 
particularly so when it takes its origin in the vertex, and because of 
greater ease of infection. Air-infection may incur in any basal fracture 
by fissures extending into the various air-containing cavities—nose, ears, 
sinuses, etc. They are then practically compound, though invisible. 
The general prognosis will depend, first, upon the injury to the cranial 
contents; second, upon the possibility of infection. Statistics are abso- 
lutely unreliable, although always possessing interest. Numerous 
museum specimens show the perfection with which bony repair may 
occur and the admirable way in which compensation is afforded for 36 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
defects. Suppuration after basal fractures is mainly that due to puru- 
lent basal meningitis, in which case the brain-symptoms dominate in the 
clinical picture, while the appearance of a single drop of pus in the ear 
or upon the surface is of the greatest significance. The conversion of a 
serous outflow (e. g. from the ear) into purulent fluid is also pathognomonic. 
Various paralyses, principally of the cranial nerves, may follow this 
injury and prove temporary or permanent. Diagnosis is often made by 
the study of these special nerve lesions. 
Diagnosis.—The most significant diagnostic features are— 
1. Spread of blood from the point of fracture until it appears as an 
ecchymosis at certain points beneath the skin. This will occur early in 
some cases, late in others. It may appear beneath the skin or beneath 
the conjunctiva or other mucous membranes, even in the pharynx. 
Occurring about the mastoid, it implies fracture of the middle or pos- 
terior fossa ; about the eyelids, of the anterior fossa. Beneath the bulbar 
conjunctiva, it means extravasation along the optic sheath, probably 
from within the dura. In fractures of the posterior fossa it will come 
to the surface of the neck, but only after two or three days. The 
ecchymoses about the lids or orbits occurring after two or three days 
mean more than those occurring within these days, since the latter may 
be caused by external bruising. The globe of the eye may be pushed 
forward by blood accumulating within the orbit. Exophthalmos thus 
produced is therefore most significant, though not common. 
2. Escape of serous fluid, blood, or brain-substance from the cavities 
of the skull. Hemorrhages from this cause occur most often from the 
ear, the petrous bone being tunnelled with various canals through which 
blood may thus escape. One should, however, assure himself in every 
instance that the blood is really escaping from the ear, and not from 
some trifling wound of the external soft parts, the soft walls of the 
meatus, or the tympanum itself. Profuse hemorrhage can probably only 
come from a basal fracture. Escape of serous fluid is usually noted as 
a sequel to hemorrhage, although it may begin almost immediately after 
an injury. Rarely more than twenty-four hours elapse before it begins 
to flow, if at all. The quantity of fluid discharged is sometimes aston- 
ishing. It may occur in frequent drops or during expulsive efforts, like 
coughing, or may ooze in such a way as to be insensibly collected by the 
absorbent dressings. In average cases the amount in twenty-four hours 
is from 100 c.c. to 200 c.c. : 800 c.c. have been noted in occasional 
instances, and in a very few still more. 
Cases characterized by escape of fluid from the ear usually belong in 
one of the following categories : 
(а) Those in which there is copious and continuous discharge setting 
in early after injury, in which one may with reason suspect a fissure of 
the petrous bone extending into the subarachnoid space. 
(б) Cases where the escape does not occur until the second day, and 
which are preceded by hemorrhage. 
(c) Those in which a small quantity of fluid trickles slowly away, 
either with or without previous hemorrhage. Here diagnosis is uncer- 
tain, but prognosis is good. 
In other instances the fluid may escape through the Eustachian tube 
into the pharynx, whence it may escape by the nostrils or be swallowed. FRACTURES OF THE BASE OF THE SKULL. 
37 
The escape of brain-substance is rarely noted, and obviously implies 
such serious injury as to make the prognosis of the worst. 
3. Disturbance of function along particular cranial nerves, paralysis 
of which is often produced by fractures of the base, particularly those 
involving the foramen of exit of the nerve involved; in which case the 
nerve may be lacerated or injured by the fragment of bone. 
4. In addition to these distinctive features there will be in the 
majority of instances brain-symptoms, either of contusion or compression, 
varying in severity within all possible limits, but adding their weight to 
the value of the testimony. These will soon be considered by themselves. 
Other and unusual signs of basal fracture may occur, such as com- 
munication between the cavities of the petrous bone and the mastoid 
cells, and leading to the formation of pneumatocele, or emphysema of the 
overlying soft parts, observed mostly about the orbits, where the nasal 
cavity is as well involved. 
Treatment.—The treatment of basal fractures is mainly symptom- 
atic. The tirst effort should be to make antiseptic all those parts of 
the skull involved, which means to shave the scalp; to thoroughly 
cleanse and irrigate the external ear and the auditory meatus, using a 
head mirror and ear speculum for this purpose, if possible; to tampon 
the meatus with antiseptic cotton ; to provide a copious absorbent dress- 
ing for such fluid as may escape, and to change this frequently; to 
cleanse the nasal cavity so far as possible, as well as the conjunctival 
sac when necessary, for all of which the peroxide of hydrogen is most 
serviceable. All of this should be done promptly, while at the same 
time studying the patient for evidence of brain injury or of involve- 
ment of special nerves. By the time these measures are thoroughly 
carried out a decision at least as to the necessity for immediate operation 
should have been reached. Evidence of brain-compression wanting, and 
in the absence of external or compound injury, the patient may be left 
at rest, with cold applications to the head and active purgation. In many 
of these instances benefit follows the application of a number of leeches 
to the mastoid region and to the occiput. Operation is called for later 
only when brain-symptoms supervene, these consisting for the most part 
of evidences of compression, either from blood or from pus, since com- 
pression from other causes must have been acting at the time of the first 
examination, and should have been recognized at that time. When 
direct fractures are evident the possibility of the entrance of foreign 
bodies must be also remembered. Thus, penetrating fractures of the 
base have occurred through the orbit as the result of accident or assault, 
and such weapons or implements as foils, ramrods, drumsticks, canes, 
umbrella points, etc. have been known not only to penetrate into the 
brain, but perhaps to leave some portion of their substance—e. g. a foil 
tip or an umbrella tip—within the cranium after their withdrawal. 
These are cases which call for special and delicate manipulation not comprised 
within the ordinary treatment of basal fractures. They are usually compound 
fractures of the base, and are mentioned here mainly to illustrate the judgment 
and surgical acumen that may be called for in many of these instances. These 
are, of course, cases justifying more or less extensive incision and exploration, as 
well as necessitating the removal of a foreign body when present, since its remain- 
ing would in all probability entail either a prompt meningitis or later brain- 
abscess. 38 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
Separation of sutures, known also as diastasis of the same, is the 
occasional result of injury instead of, or complicated with, fissures or 
other fractures. It is the result of violence, and is virtually a specific 
form of fracture, from which it differs in no essential particular. Dias- 
tasis can only take place along lines of previous suture, but it is possi- 
ble that Wormian bones may be thus loosened. Sutures thus separated 
ordinarily heal by fibrous repair rather than osseous union. Diagnosis 
is ordinarily possible only as they are exposed to view, although dis- 
placement in the middle line or along known suture lines may be per- 
haps regarded as diastasis. 
The treatment differs in no respect from that of other fractures. 
Injuries to the frontal sinuses occasionally complicate fractures of the 
skull. These sinuses vary exceedingly in different individuals; are 
rarely truly symmetrical; are not found in the very young; they con- 
nect with the nose in such a way that emphysema of the frontal region 
is quite possible, while air may even be blown beneath the periosteum 
or may communicate with the interior of the cranium. In wounds of 
the frontal region the sinuses are occasionally opened—a fact of import- 
ance, since infection of the Schneiderian membrane may occur and 
endanger life, mainly because of the retention of infectious products 
within its cavities. Moreover, by such wounds the ethmoid may also be 
injured. Pus which escapes from these sinuses and from the ethmoidal 
cells is usually thin and bad-smelling. Long continuation of suppura- 
tion after such injuries probably means necrosis and formation of 
sequestra. 
With the recognition of certain portions of the brain whose function 
is now generally recognized and described, as well as with the more 
exact knowledge regarding the entire encephalon, the outcome of many 
recent studies, the teaching of the past with regard to the nature of 
various brain lesions has been essentially modified. Especially is this 
true with regard to the distinction formerly emphasized as between 
concussion and compression. In discussing brain injuries we must, first 
of all, distinguish between traumatic disturbances of the entire endo- 
cranium and localized injuries to the brain or particular vessels and 
nerves entering into its composition. With regard to the first, it is 
possible that the entire blood or lymphatic circulation within the cranium 
may be affected in such a way as to influence its nutrition and function, 
by which means activity and function are mildly or seriously perverted. 
The immediate effect of severe injury to any part of the body is reflex 
vasomotor spasm, which constitutes the essential feature of the condition 
known everywhere as shock. It is this condition, with its strong local 
expressions, which used to be known as concussion of the brain. When 
studied upon its merits, it is found to be indistinguishable from shock pro- 
duced by injuries to other parts. It will be correct, then, to make the 
general statement that the condition for so many years taught and recog- 
nized as concussion is but shock following injury to the head. This 
makes no further demands upon the question of pathology than those 
prompted by any traumatic disturbance. 
INJURIES TO THE BRAIN AND ITS ADNEXA. CONCUSSION OF THE BRAIN. 
39 
Through the mechanism of the cerebro-spinal fluid rapid alterations of pres- 
sure and of the volume of the brain are produced. There is an easy path between 
the inelastic cranial cavity and the exceedingly elastic and accommodating spinal 
canal, which latter serves as a reservoir for the fluid which may be pressed out of 
the cranium when brain-pressure is increased. And, while the subdural and sub- 
arachnoid spaces are each of them absolutely closed sacs and do not communicate 
one with the other, there, nevertheless, is ample accommodation within each to 
permit a constant equilibrium of pressure under ordinary circumstances, as 
between the spinal cord and the cranial canal. The brain expands in volume 
with every systole of the heart, while with every diastole it contracts. Its size is, 
moreover, modified by the motion of respiration. Under these extremely accom- 
modating conditions it is scarcely credible that external injuries which leave no 
internal marks of violence should do anything more than disturb the equilibrium 
of fluid distribution. 
Concussion of the Brain. 
We inherit tjie term concussion from the earlier masters of our art, 
by whom, however, it was used in a much broader sense than of late. Its 
modern significance was given to it by Boirel, who made it apply to a 
group of cerebral symptoms the result of injuries not accompanied by 
fracture or perceptible laceration of vessels—symptoms varying in inten- 
sity and duration. 
In 1705 the subject was first studied anatomically, and then by Littre, whose 
inferences were natural from insufficient investigation, and who ascribed trifling 
alterations of brain-tissue to the inevitable results of serious injury to the skull. 
Later, Petit formulated the statements which until recently have been generally 
held, that as the result of external violence vibrations are produced which are 
continued to the brain-substance and cause oscillations or other trifling molecular 
changes. There has always been this difficulty, however, that concussion was 
rarely followed by death—that the injuries which were followed by recovery could 
not be accurately estimated, while after those which were followed by death the 
brain was almost invariably found the subject of at least minute disturbances, such 
as capillary hemorrhages, trifling lacerations, etc. The physiologists have taught 
us that the most minute injury—at least in certain parts of the brain—is enough 
not only to disturb, but to destroy, function ; and we can maintain with probable 
accuracy that in so-called fatal cases of concussion we have to do with something 
more than mere molecular disturbance without discoverable effect. Moreover, from 
mere oscillation we have the right to expect that after the lapse of a certain time 
there should be complete or almost complete repair; in which hope, however, we 
are disappointed so far as clinical experience goes. And so it has happened that 
the theory of communicated vibrations, so long unchallenged, has of late been 
almost completely abandoned, at least in those cases which are followed by long- 
continued or permanent disturbance. Experimentation upon animals has done a 
great deal to lead to this change of view, it being found that any injury to the head 
which seriously disturbs function of the brain gives appearances of congestion of 
membranes or of the substance of the brain, with minute vascular ruptures, trifling 
lacerations, etc. The most valuable researches in this connection have been con- 
ducted by Duret, who has apparently proven that when an impression is made 
upon one side of the skull, even though it be instantaneous, produced by a blow, 
it is followed by elevation at a point opposite, permitted by the elasticity of the 
bone. There occurs also a violent precipitation of the liquid contained within and 
around the brain in the direction of the injury, with damage to the vessels and 
even the substance of the brain. These separate traumatisms he divides into three 
stages: 
a. Of excitation ; 
b. Of paralysis; 
c. Of reaction; 
during the first of which there is a tetanic condition of muscles, often with violent 
expulsion of urine and fseces, increase of vascular pressure, and irregularity of the 
heart. This stage, sometimes only a few seconds in duration, is succeeded by the 40 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
paralytic stage, marked by vascular relaxation, insensibility, rapid respiration, 
temporary paralysis of muscles, etc. The third stage is characterized by elevation 
of temperature, and often by mental excitement, merging even into delirium or 
mania. 
Our present position is practically this : The possibility of pure con- 
cussion of the brain—i. e. disturbance of brain function without gross 
mechanical lesions—is admitted, but its general frequency is denied. 
When present it must either pass away quickly, the condition being 
equivalent to that called “stunning” by the laity, or, if it assume dis- 
tinct form, its signs and symptoms are indistinguishable from those of 
shock, consisting essentially of rapid and feeble pulse, quick and shallow 
respiration, pallor of the skin, copious perspiration, complete or partial 
unconsciousness, muscle inco-ordination, with lack of sphincter control, 
occasional vomiting, the pupils usually reacting to light. 
The treatment for this condition is essentially that for shock, plus 
whatever may be called for in the way of attention to injuries about the 
head—e. g. sewing up a scalp wound, etc. 
Contusion. 
The condition of shock (cerebral concussion), when of pure type, 
passes away with reasonable promptness, especially when aided by sur- 
gical treatment. Anything which persists in the way of muscle-paralysis, 
disturbance of function of nerves of special sense, or other sign of any 
importance, indicates something more than mere vibratory disturbance: 
it implies mechanical lesion which could be perceived by the eye were 
the parts exposed, and constitutes the condition now generally known as 
contusion. This implies the existence of trifling exudates or hemor- 
rhages, which require not only absorption, but even cicatrization. Con- 
tusion pure and simple differs from ordinary laceration as a contusion else- 
where may differ from a wound. It cannot be separated, however, from 
conditions in which there are minute separations of continuity and actual 
lacerations. It may be divided into three post-mortem forms: general 
hypercemia, with or without oedema; punctate or miliary hemorrhages; 
and thrombosis of minute vessels, which may occur separately or together. 
Moreover, there may exist similar lesions in the meninges, constituting 
meningeal contusion. Ordinarily, minute vessels of the pia are ruptured 
and blood is effused in small and thin patches over various parts of the 
brain. The so-called compression apoplexies of certain authors are insep- 
arable from the conditions above described. Such minute blood-clots are 
only to be distinguished upon very careful sectioning of the brain, and 
are found most often in the region of the medulla and along the floor 
of the fourth ventricle. They are probably caused by the forcing into 
the fourth from the lateral ventricles of the fluid contained in the latter. 
Symptoms of Contusion.—When the ordinary symptoms of shock 
which follow all severe injuries to the head, especially when the deep 
lesions are not too severe, fail to disperse in a short time under proper 
treatment, and when, in particular, new and irregular symptoms are 
superadded to those of shock alone, we have every reason to think that 
the intracranial condition is one of contusion rather than of shock. 
When, for instance, mental agitation changes into delirium, when the BRA IN-DRESSURE OR COMPRESSION. 
41 
rapid, feeble pulse becomes stronger and slower, the respiration deeper, 
the limbs moved in inco-ordinate ways, the speech disturbed from 
muscle inco-ordination, the patient selects wrong words, or when the 
mental condition becomes more serious and stupor or coma takes the 
place of delirium, while external irritants have less and less effect, and 
when the pupils gradually enlarge while failing to respond to light,— 
we may say that the condition of contusion is making itself apparent. If 
along with muscle-uncertainty there be also muscle-spasm or rigidity, 
with fixation of the fingers in the athetoid position, the evidence to this 
effect is increasing. If with all this the thermometer fails to show that 
an active inflammatory condition—i. e. meningitis—is prevailing, the 
diagnosis may be regarded as certain. Error may possibly arise when 
there are evidences of alcoholism. Coma following head injury ought 
not to be ascribed to the alcoholic condition except by the strictest pro- 
cess of exclusion. Temperature alone will be of the greatest service in 
this direction, since in alcoholism it is usually subnormal. In apoplexy 
and non-traumatic hemorrhages it is also usually subnormal at the com- 
mencement of the attack, rising to normal, and remaining there if the 
patient recover, but continuing to rise in cases where the prognosis is bad. 
The treatment of brain contusion must be managed largely in 
response to special symptoms. Physiological rest, attention to scalp 
wounds, fractures, etc., shaving of the scalp, application of ice to the 
head, with such stimulation to the heart as may be necessary in extreme 
cases by subcutaneous administration of strychnia, atropine, etc., by 
local fomentations over the epigastrium, or by immersion in a hot bath 
when surroundings permit it,—these in a general way constitute most 
of the methods of treatment in contusion. When only symptoms of 
diffuse and minute lacerations can be recognized, the use of the trephine 
is impracticable, even unjustifiable, save when indicated by some exter- 
nal marking—i. e. compound fracture or the like. When localizing 
symptoms are present the trephine is, of course, called for. When the 
skull injury is recognized as a basal fracture, venesection or the appli- 
cation of leeches behind the ears will be most serviceable. In every 
such case there is the greatest necessity for regulating the excretions and 
preventing auto-intoxication. For this purpose diuretics and laxatives 
must be used, often in conjunction with intestinal antiseptics. The 
catheter should be resorted to whenever indicated by the condition of 
the bladder, which should be carefully watched. As the days go by and 
patients lie more or less helpless and inert, the greatest care should be 
exercised for the prevention of bed-sores. When, still later, patience is 
tried to the utmost because mental inertness, muscle-rigidity, etc. fail to 
disappear, I would advise the use of potassium iodide internally, having 
seen great benefit from its use in many cases, although acknowledging 
that it is given on purely empirical grounds. 
Brain-pressure or Compression. 
That the cranial contents—brain, blood, lymph, and cerebro-spinal 
fluid—completely fill the cranial cavity has been already amply shown, 
as well as that there is no room for anything in the shape of a foreign 
body without seriously affecting the equilibrium between the brain and 42 
INJURIES AND SURGICAL DISEASES OE THE HEAD. 
the contents of the spinal canal. When, however, any foreign substance 
exerts pressure upon the brain, the results are invariably the same, be 
this substance what it may, and compression signs are always the same, 
no matter what the compressing cause. Reduction in size of the cranial 
cavity—i. e. compression—may be produced— 
1. By altering the circulation of its surroundings (e. g. depressed 
fractures or by direct pressure); 
2. By increase in the quantity of cerebro-spinal fluid or of the vol- 
ume of the brain, which latter may be produced by oedema, by serous 
exudate, or by actual hypertrophy ; 
3. By foreign bodies, which may enter the skull from without; 
4. By pathological conditions—collections of blood or pus, tumors, 
etc., which may be produced either from the brain-substance, its con- 
taining bone or membranes, or its vessels. 
In every one of these conditions the size and tension of the brain are 
affected. The cerebro-spinal fluid is mainly involved in acute, not in 
chronic, conditions. Avery slow reduction of the diameters of the skull 
produces such slow alterations of pressure as to cause a minimum of 
disturbance. So far as compression from traumatic influences is con- 
cerned, we distinguish mainly between— 
1. Compression by extravasation of blood ; 
2. By fractures of the skull with depression, or by foreign bodies 
penetrating from without; 
3. By products of acute infectious inflammation due to septic infec- 
tion from without. 
The result common to all of these is increase of intracranial tension, 
and its consequence is a less rapid flow of blood and an altered blood- 
supply to the brain and its membranes. 
Experiment has completely established that in compression of the brain cere- 
bro-spinal fluid is forced by pressure into the spinal canal, whose membranes are 
more elastic, and which thus help to accommodate it; but it has been clearly 
established that compression of the brain by one-sixth of its volume of any mate- 
rial is essentially fatal, and that much less is at least serious. That fractures with 
depression produce sometimes serious, at other times trifling, symptoms is due 
largely to the varying accommodation of the spinal canal. Both experiment and 
observation alike seem to confirm the view that consciousness pertains to the cortex 
as a whole, and that unconsciousness is an inhibitory or paralytic condition which 
is produced in compression. 
Temperature is a matter of great importance in studying compression 
and foretelling its consequences. Elevation of temperature is an early, 
continuous, and constant symptom in these cases. If temperature be 
subnormal and subsequently rise, prognosis is bad. Variations of tem- 
perature are more reliable guides than conditions of consciousness. As 
Phelps has remarked, in no condition except sunstroke is temperature so 
uniformly high as in cases of serious encephalic lesions. 
Symptoms.—As indicated above, the symptoms and signs of com- 
pression are practically identical, no matter what the compressing cause. 
When this cause acts instantly there is no time afforded for differentia- 
tion, but when it occurs slowly we note the following symptoms, and 
about in the order as here presented : Irritability or restlessness ; visceral 
disturbances ; pain ; intense cephalalgia ; congestion of the face ; narrow 
pupils; augmented pulse, often seen in the carotids. If compression BRAIN-PRESSURE OR COMPRESSION. 
43 
occur more rapidly, torpor quickly succeeds erethism, after which patients 
vomit, have convulsions or at least convulsive motions, speech is dis- 
turbed, and stupor comes on, from which they neither awake nor can be 
awakened until the compression is relieved. All of these indications 
refer to involvement of the cortex, which is generally regarded as the 
seat of consciousness as well as of projection and imagination. During 
the night of the senses produced by pressure upon the cortex only the 
automatic basal apparatus and that of the spinal cord continue in more 
or less disturbed operation. Of all the general functions, consciousness 
vanishes first and returns among the last. When intracranial pressure 
has reached a certain point, epileptiform convulsions result, varying in 
intensity, affecting all the limbs, and terminating perhaps with rigidity. 
These are an expression of high pressure. Similar convulsions occur in 
various head wounds, explanation for which is the result of pressure, 
which, though not extensive, may produce alteration in the circulation 
with its disastrous consequences. The later and constant evidences of 
compression, and those which in aggravated cases supervene at once, are 
reduction of pulse-rate, due to the action of the pneumogastric, which 
suffers first an irritation and later a paralysis. The pulse becomes not 
only slackened, but full; the respiration-rate is correspondingly reduced, 
so that breathing during coma is deep, slow, and often stertorous. This 
feature of stertor is an expression of paralysis of the palatal and pharyn- 
geal muscles, which flap, as it were, in the air-current. Vomiting, which 
may occur before brain-tension has risen high, is not met with in the 
most serious cases. Coma is absolute, and nothing can arouse the 
patient. 
Along with these signs, the most important other indications are the 
paralyses, which may consist of monoplegia, hemiplegia, or paralysis of 
individual muscle-groups according as pressure is made upon a limited 
area or upon an entire hemisphere. By the division of the cranial cav- 
ity by the falx and the tentorium it is divided into three chambers, in 
any one of which pressure may be more manifest than in the others. 
Nevertheless, a serious compressing cause will affect the tension of the 
cerebro-spinal fluid and produce general expression of pressure. The 
pupils often vary, and responsiveness to light is occasionally noted. 
Nystagmus and ocular rotation may be occasionally seen. Choking of 
the optic disk is also a frequent phenomenon, to be recognized only upon 
ophthalmoscopic examination. This is due to pressure in the subdural 
and subarachnoid prolongations along the optic nerve. In milder cases 
of chronic compression disturbances of vision are of very great clinical 
importance. These pertain especially to diagnosis of hydrocephalus and 
of brain tumors. When they occur immediately after injury, and re- 
main, they depend upon laceration or other severe injury of the optic 
nerve. Those which quickly disappear depend mainly upon pressure of 
blood, which is reabsorbed, while those which are later in their appear- 
ance depend upon later intracranial complications. A unilateral lesion 
of the optic nerve depends most often upon injuries to it within the optic 
canal. When the lesion is bilateral the cause lies deep. General paral- 
ysis may be of the type of hemiplegia, single or double ; i. e. by “ double ” 
I mean paralysis of the entire voluntary musculature of the body, which 
necessarily implies serious, too often fatal, hemorrhage. 44 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
PROGNOSIS:V—This depends in large degree upon the nature of the 
compressing e#use and of the possibility of its removal. While the 
-nature'--of the tfeame may ordinarily be determined, how much can be 
-onI pitslied' 1 >y way of removal may often not be foretold before the 
operation at which this should be attempted. In every acute case it is 
desirable to make this attempt early, since high pressure, which may be 
borne for a few moments, is fatal if continued. Compression to any 
serious degree, left unattended to, is usually fatal. So soon as paralysis 
in circulatory and respiratory centres is apparent the beginning of the 
end is at hand. Another reason for hastening operation, when indicated, 
is that acute softening of brain-tissue comes on promptly, as well as 
general cerebral oedema, which has destroyed many a patient from the 
second to the fourth day after injury. 
When the pressure is localized, especially upon a limited area, this may suffer 
intensely, and the balance of the brain to a minor degree. So soon as this local 
pressure be relieved and circulation restored resumption of function is quite pos- 
sible. Incomplete paralyses are the final results of extravasations, which often 
seem to be localized with sufficient accuracy to warrant operation. In some 
instances the brain appears to acquire tolerance for pressure when not too serious. 
This is shown by recovery, especially of children, after injuries which have left 
them unconscious for days. ( Vide Plate II.) 
Treatment.—The treatment of compression is summed up in one 
phrase—i. e. to remove the cause when possible. The only cases in 
which this rule may be safely disregarded are those where the attempt 
to remove the cause means more danger than to leave it unremoved. 
This is not true, however, in the ordinary cases of bone depression, men- 
ingeal hemorrhage, etc. Before operation, however, or as a substitute 
for it in cases of minor severity, it may be well to assist venous outflow 
by venesection, by which blood-pressure is reduced. In these cases this 
may well be done from the temporal veins or external jugulars, with the 
patient in the semi-upright position. Drastic purgatives may also be 
employed in order to utilize intestinal outpour as a stimulation to resorp- 
tion of cerebro-spinal fluid. The physiological action of cold (ice-bags) 
may also be secured for the purpose of contracting the cerebral arteries. 
But all these measures are only to be resorted to when there is uncer- 
tainty as to the wisdom of operating, since when operation is clearly 
indicated it should be done at once, and should take precedence of every- 
thing else. This operation means ordinarily the procedure to which 
the now general term trephining- has been applied by common consent, 
and comprises any measure by which the skull is opened at a suitable 
place and the dura or the underlying cortex exposed to such extent as to 
permit removal of the compressing cause. Whether the opening be 
made with trephine (annular saw) or with the straight or revolving saw, 
with bone-chisel, with bone-forceps, or with anything else is a matter of 
choice on the part of the operator. So, too, removal of the compress- 
ing cause should include the elevation of depressed bone, the removal of 
dislodged particles as well as of all foreign bodies, the cleaning out of blood- 
clot, the checking of hemorrhage, and the closure of the wound, with or 
without drainage or counter-opening at some other part of the skull, as 
may seem wise in special cases. This entire procedure comes now under 
the name of trephining, and must be painstakingly gone through with 
in most instances. PLATE II. 
FIG.I. 
FIG.2. 
Fig. i.—Compound Fracture of Cranium, with Depression; Fracture of Bones of Face; 
Extradural Clot from Rupture of Middle Meningeal Artery. 
Fig. 2.—Horizontal section of same, showing Depressed Fracture of Bone; C, Extradural 
Clot; D, Laceration of Brain-substance, with extensive Intracerebral Clot; F, Same condition 
produced by Contrecoup. Punctate Hemorrhages and Minute Lacerations at Numerous Points, 
characteristic of Contusion of the Brain. (Anger.) INJURIES OF INTRACRANIAL VESSELS AND SINUSES. 
45 
The operative manoeuvres will be discussed by themselves in another 
portion of this chapter. 
Injuries of Intracranial Vessels and Sinuses. 
Intracranial hemorrhages may occur— 
а. From external sources through the broken bone or between it and 
the dura (extradural); 
б. Beneath the dura, between or into the membranes (subdural); 
c. Into the brain-substance proper or the ventricles (subcortical or 
intraventricular). 
The vessels whose injuries are most often under consideration are the 
meningeal arteries, the sinuses, the small vessels of the membranes, and, in 
very rare cases, the internal carotid. The arteries, like the sinus-walls, 
may be ruptured either by substances forced in from without or by sheer 
laceration. The longitudinal sinus is most liable to injury from without. 
When this sinus is exposed it may be dealt with either by suture if the 
wound be small, or by ligation, or by tamponing with iodoform gauze. 
Fig. 12. 
Compression following hemorrhage from the middle meningeal artery (Helferieh), 
Hemorrhage from this source is ordinarily not difficult to check. Fatal 
air-embolism has resulted through an opened sinus not properly plugged. 
The other sinuses are very rarely injured, as by gunshot wound, fracture 
of the base, etc. The sinuses have also been injured by compression of 
the skull during parturition. Bleeding from the sinus is usually indis- 
tinguishable from that from a meningeal artery, save that the former 
occurs more slowly. 46 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
Injuries to the middle meningeal artery naturally occur in the 
immediate neighborhood of this vessel, which is not infrequently rup- 
tured by contre-coup. The artery runs sometimes in a groove of the 
bone, sometimes in the dura, and sometimes entirely in the bone. The 
more it lies within the bone, the more likely it is to be ruptured when 
this part of the skull is fissured. Basal fractures often follow the groove 
for this artery. The anterior branch is more often injured than the pos- 
terior. Extravasations from this source are more common than from all 
others combined, the amount of blood varying within wide limits. Two 
hundred and forty grammes of blood-clot have been known to collect, 
and the dura to be separated down to the very base of the skull. I 
have repeatedly taken away at least a small teacupful of blood-clot in 
such cases. 
The symptoms of this hemorrhage are, of course, those of com- 
pression, while extravasation may be rapid and quickly fatal, delayed 
for some time, or may take place in two stages, the first but slight and 
producing no coma. New clots are always dark and disk-shaped, thick 
in the middle, with a definite margin. As the clots become older they 
become more adherent and difficult to remove. The symptoms of 
meningeal hemorrhage consist of an interval of consciousness or lucidity 
after injury, followed by epileptic or spastic symptoms, alterations in the 
pupils and pulse, unconsciousness passing into coma, and stertorous respi- 
ration. There may or may not be external evidence of head injury. 
The character of the paralysis (hemiplegia) may indicate that the clot 
is really upon the side opposite to that of the skull which shows evi- 
dence of injury. In this case arterial laceration is the result of contre- 
coup. According to the rapidity of the symptoms is the extent of the 
primary lesion. Meningeal hemorrhages involve immediately the motor 
area, which makes diagnosis all the easier. 
Treatment.—The majority of these cases are fatal when left alone. 
Hence the treatment is essentially operative, and should be prompt. Of 
257 cases collected by Wiesman, 147 were treated expectantly, and of 
these 131 died ; while of 110 cases operated on, only 30 died; and this mor- 
tality-rate could be greatly improved upon in favorable cases. Nothing 
could speak more eloquently for operation than such statistics. The 
skull should be opened in the indicated area, clot removed, bleeding 
vessels sought for, counter-opening made in cases where the clot is very 
large, and drainage established through and through. 
One of the earliest and most instructive cases on record as corroborating bold 
measures in these cases was that reported by Parker, who in the absence of exter- 
nal indication, inferring that he had to do with meningeal hemorrhage, trephined 
first on one side, and, finding no clot, trephined again upon the other side: here, 
finding nothing between the dura and the bone, he incised the dura, removed a 
large extravasation, and saw his patient completely restored to health. This was 
so late as 1877, at which time it was regarded as an exceedingly bold procedure; 
which will show what rapid advances have been made in cerebral surgery. It is 
more important to remove the clot than to find the artery. Consequently, the 
trephine should be applied at the point most indicated by a study of paralysis. In 
other words, the principles of cerebral localization should guide, rather than those 
of arterial anatomy. 
Injuries to the carotid within the cranium are exceedingly rare. 
Still, it has been injured in basal fractures and penetrating wounds. LACERATIONS AND INJURIES TO THE RRAIN-SUBSTANCE. 
47 
Development of arterio-venous aneurisms after basal injuries is 
occasionally noted. They will give rise occasionally to pulsating exoph- 
thalmos. Pulsating tumors within the orbit which push the eye for- 
ward not infrequently occur after serious head injury. Of 77 cases col- 
lected by Riving ton, 41 had a traumatic origin. 
Subdural hemorrhages are not infrequent in the skulls of the new- 
born, and constitute the so-called apoplexia neonatorum. They may 
occasion convulsions and paralyses of irregular type, while if the extrav- 
asations become infected multiple abscess may result. 
In adults subdural hemorrhages are, for the most part, connected with those 
brain lesions which have been already spoken of as contusions. They may be the 
starting-points for pachymeningitis. Their most common results are disturbances 
of consciousness and mentality. Paralytic dementia follows in some of these cases. 
Extensive subdural hemorrhage may give a clinical picture corresponding to extra- 
dural. Disseminated minute ecchymoses constitute minute focal lesions, which 
are, however, usually so distributed as to confuse and prevent accurate diagnosis. 
Apoplexy or intraventricular hemorrhages, especially from the lenticulo-striate 
artery (Charcot’s “artery of hemorrhage”), have until very recently never been 
regarded as warranting surgical interference. Of late, however, especially in the 
ingravescent or progressive forms, ligature of the common carotid has been of some 
service, though in order to render this effective ligature must be made very early 
in the course of the case. 
Traumatic intraventricular hemorrhage occurs in much the same 
way as meningeal, by contre-coup. Individuality of symptoms is lost 
in the general comatose condition of the patient, but when operation is 
performed, as it is usually best to perform it, if no extradural clot be 
found and if brain-tension be evidently increased, the dura should be 
opened; after which, if no subdural clot be seen, the ventricles should 
always be tapped with the exploring needle. In this case, if blood be 
removed by aspiration, a knife should be passed directly into the ven- 
tricle, after which blood will promptly escape, if present. Dennis was 
the first to diagnose the presence of intraventricular clot and to deliber- 
ately incise into it, and I have myself repeatedly imitated this procedure, 
both with and without success. 
Lacerations and Injuries to the Brain-substance. 
These have been already nearly sufficiently alluded to under the term 
contusion of the brain. They may be divided into those which occur 
with or without fracture of the cranial bones. The term contusion was 
first suggested by Dupuytren. The condition comprises all degrees of 
injury, from the most minute local disturbances to lesions involving the 
entire hemisphere. The milder forms show a sprinkling of punctate 
hemorrhages, numerous in the centre of the injured area, the surround- 
ing tissue taking on a more or less diffused tint, which fades out toward 
the periphery, discoloration being due to the imbibition of the coloring 
matter of the blood. In more extensive injuries clots as large as peas 
or larger are imbedded at various points, each surrounded by its area of 
discoloration. When foreign bodies have been driven into the brain, 
the tissue is also discolored, while various foreign materials may be met 
with. In an instance of great violence there may occur absolute rup- 
ture of brain-tissue extending from cortex to ventricle. 48 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
When the body which causes the injury is small the contusion will be found 
usually close to the site of injury or perhaps opposite to it (contre-coup). The 
cerebro-spinal fluid is an important agent in the production of disseminated and 
even distant lesions. When the lateral ventricles are compressed their contained 
fluid seeks to escape through the Sylvian aqueduct into the fourth ventricle and 
the central canal of the cord, all of whose walls may be materially injured by this 
sudden distention. In these locations especially, then, we expect to meet with 
minute extravasations. They have been seen even as far as the lumbar portions 
of the cord. The combination of contusion and intrameningeal hemorrhage is 
most common, and is that portrayed in Plate II. It is the feature of contusion 
which constitutes the most serious complication and the most serious obstacle to 
recovery after operation for removal of sub- or extradural clot. 
Prognosis.—Prognosis depends in large degree upon escape from or 
occurrence of infection. In infective cases the principal dangers are 
from blood-pressure and from later oedema or acute softening. Brain 
lacerations may heal by cicatricial repair, but usually with some perver- 
sion, at least trifling, of function. 
The possibility of cystic degeneration of large or small clots is one of very great 
importance. (See Cystic Softening, p. 392, Volume I.) A blood-clot now within 
the cranium which fails to resorb is essentially a haematoma, in whose interior soft- 
ening and conversion into a cyst may easily occur. These cysts make room for 
themselves at the expense of surrounding brain-tissue, and when located in the 
motor area give rise to localizing symptoms as well as to epileptic convulsions. 
They may be often diagnosed with certainty after an accurate history of the case 
and the study of the phenomena which it presents. As they grow older their walls 
become firmer, and it is often possible to dissect them out as one removes any other 
cyst from its surroundings. 
That foreign bodies may be encapsulated and remain without producing disturb- 
ance is now well known. As a rule, however, though encapsulated, they produce 
symptoms like headache, vertigo, etc. 
Fig. 13. 
Bullet imbedded in anterior fossa (U. S. Army Med. Museum). 
In penetrating wounds the canal usually terminates in a blind extremity, 
although points of knife-blades or other foreign bodies may remain in its depths. 
It is important to remember that the brain may be penetrated through the orbit or 
the nose, and that small substances introduced in this way may cause subsequent 
fatal meningitis. Thus, fragments of glass, umbrella tips, ends of foils, knife- 
blades, etc. have produced cases whose history is interesting reading, but which 
cannot be detailed here. Needles have been found in the brain which must have 
been introduced long before, probably in infancy, and which appear to have caused 
little or no disturbance. . 
Symptoms.—The general features of brain lacerations are those of PROLAPSUS AND HERNIA CEREBRI. 
49 
contusion already alluded to, somewhat exaggerated in many cases. So 
long as the disturbances are minute, even if multiple, or the foreign 
body small, compression symptoms are not produced, or at least in very 
incomplete degree. Minute diagnosis is, of course, impossible. The 
most essential thing is to decide upon the question of operative inter- 
ference. In the absence of distinctly localizing symptoms or other 
external markings, which of themselves would indicate operation, it is 
usually abstained from. Upon the other hand, a lesion which can be 
distinctly localized is probably due to extravasation large enough to be 
quite probably reached by opening the skull; and, unless there be other 
and sufficient reason to the contrary, this should be done. 
In many instances, however, contractures or paralyses of muscle- 
groups occur later, and are followed by spastic conditions which may be 
permanent. More can be done in these cases by massage, by internal 
medication, perhaps with external counter-irritation, than by distinctly 
surgical procedures. Both albuminuria and glycosuria are known to be 
the result of injuries herein referred to, as well as bulbar paralysis and 
disturbances of special senses. More immediate dangers after these 
head injuries are those of broncho-pneumonia or hemorrhagic or oedem- 
atous infiltration of the lower lobes of the lungs—conditions often 
spoken of as hypostatic pneumonia, much resembling those produced 
experimentally in bilateral division of the pneumogastrics. Some of 
them are produced by paralysis of the glottis, the result of which is 
incomplete closure, with aspiration of fluids and solids from the mouth 
whose decomposition sets up an infection within the lungs which is often 
spoken of as aspiration pneumonia. Some form of pulmonary disturb- 
ance follows in perhaps one-third of the cases of the injuries above 
alluded to, and should be guarded against in every possible way. 
Treatment.—Most important of all is it to emphasize that the safety 
of these patients depends in large measure upon the treatment primarily 
received at the hands of the first medical attendant. If this be careful and 
aseptic, complications may be avoided; if otherwise, infection within 
the cranium or within the thorax is very likely to cause the patient’s 
death. Absolute and primary disinfection of all external injuries, no 
matter what may be considered the condition within the cranium, and 
rigid care with regard to the feeding of the patient and his general 
nursing, will never be more life-saving than in these instances. These 
remarks are made because contusions and the more extensive lacerations 
are rarely met with in the absence of some scalp wounds or fracture, 
which of themselves should be treated along lines already clearly indi- 
cated. When the trephine is not called for on account of external 
injury, its use should be dictated entirely by what may be judged of the 
internal conditions and by indications already considered. 
Prolapsus and Hernia. Cerebri. 
Escape of brain-matter beyond its normal level is not uncommon in 
connection with compound fractures or their sequelae. It may be pri- 
mary, escaping with the blood at the time of the accident, or secondary, 
occurring during the ensuing days. Any lesion of this kind in which 
the brain appears or can be handled is entitled to the term prolapsus, in 50 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
contradistinction to hernia, which implies that, though escaping from the 
proper cavity, it is nevertheless covered by other textures—e. g. dura or 
scalp. 
The protrusion may vary in size from a very small tumor to one the 
size of a fist. It is always the result of increased intracranial tension, 
and may be produced by hemorrhage, by serous imbibition, or as the 
result of brain-abscess. When immediate, it is of the first variety; 
when later, of the second or third. When abscess is present it usually 
delays a protrusion, which is produced by degrees. Prolapse occurs for 
the most part through large openings, such as those made by gunshot 
wounds, the trephine, etc. Prolapse proper implies laceration of the 
dura. It pertains obviously to the convexity of the skull, occurring, 
however, in exceedingly rare cases into the orbit, etc. 
The prognosis is generally unfavorable. There is always risk of 
oedema or infection, either of which may prove fatal. 
Infiltration, gangrene, suppuration, or repair by granulation may 
so disfigure and disguise the real brain-substance as to lead to error of 
diagnosis. It by no means follows that every tumor presenting 
through an opening in the skull is of this character. When gangrene 
and spontaneous separation occur, spontaneous recovery may follow, the 
stump being covered by granulations and finally roofed over by connec- 
tive tissue. 
Treatment.—Treatment in the primary cases should include the 
most rigid asepsis with removal of all foreign particles. Localized 
pressure does some good, especially in those cases where it can be tole- 
rated. Signs of abscess should always be watched for, and deep explor- 
ation is often justified or indicated. While excision, cauterization, etc. 
are often heralded as successful, they are by no means without their 
dangers. Cases that admit of it should wear a protective shield properly 
moulded to the part. Skin-transplantation, or even osteoplastic repair 
of the defect, may give good results in favorable cases. 
Injuries to Cranial Nerves with or without Lesions 
of the Cranium. 
The olfactory nerve is sometimes injured by-penetrating wounds of 
the frontal region, or, again, by infiltration of fluid along its course 
through the pores of the lamina cribrosa. In some of these latter cases 
function returns, after a while. Loss of smell is not necessarily due to 
injury to this nerve, but may be produced by the plugging of the nostril 
with blood, etc. 
The optic nerve may be injured at any point. It has been torn from 
the globe by external violence; foreign bodies may be imbedded in it, 
etc. When the lesions occur posterior to the entrance of the central 
vessels, the ophthalmoscopic picture will be normal, at least for some 
time, but when anterior to the vessel entrance changes are produced 
much resembling those of embolism of the central artery. The optic 
canal is often injured in basal fractures and the optic sheath more or 
less filled with blood, whose presence is not always easily accounted for. 
Fragments may be splintered from the canal, and these may injure the 
nerve. 51 
SEPTIC INFECTIONS WITHIN THE CRANIUM. 
The oculomotor or third nerve may be injured during birth by the pressure of 
obstetric forceps, as well as by fractures of the orbital roof or by penetrating 
wounds. Paralysis of the fourth nerve after head injury is very rare. The abducens 
is paralyzed in some cases of pulsating exophthalmos. 
Injuries to the fifth nerve are mostly observed in connection with extensive 
lesions involving as well the other cranial nerves. Anaesthesia of the trigeminal 
area after head injuries leads to a neuro-paralytic lesion of the eye, and there is 
reason to think that many cases of unilateral atrophy of the face are due to some 
injury in the neighborhood of the petro-basilar synchondrosis. 
The seventh and eighth pairs are more frequently injured—the facial, for instance, 
by the obstetric forceps during parturition at its exit from the skull, or by various 
blows from the outside. In basal fractures it alone, or with the auditory nerve, has 
been paralyzed in numerous instances. When the facial is torn across, as may easily 
happen during its passage through the petrous bone, paralysis may be immediate, 
and probably permanent. If improvement or recovery follow, the nerve certainly 
has not been divided, but the paralysis is probably due to pressure by blood-clot in 
the Fallopian canal. In other instances where facial paralysis comes on more slowly 
it is probably due to an ascending neuritis. 
Disturbances of the auditory nerve have more significance in diagnosis of basal 
fracture than those of the facial. Hemorrhages into the internal ear, or even fill- 
ing of the middle ear, may occur without fracture, but the presumption is in favor 
of such injury. 
The other cranial nerves have been known to be injured in one way and another, 
but such injuries are mere surgical curiosities, save in those cases where the lesion 
is so extensive as to determine a speedy death. 
Septic Infections within the Cranium. 
Under the general term septic infection I mean to include— 
A. Abscess; 
B. Thrombosis; 
C. Sinus phlebitis; 
D. Meningitis; 
E. Encephalitis ; 
these being in effect different manifestations of infection, the clinical 
picture differing according to the tissues and localities involved. For 
the production of these infectious conditions no special bacteria other 
than those already alluded to in Chapter III. Yol. I. are comprehended. 
Their method of activity is there discussed at sufficient length, and we 
need here only consider the various paths of infection. These may lie 
along the blood-vessels, the lymph-vessels, nerve-sheaths, and prolongations 
of the membranous sacs which extend from the cranial cavity proper. 
There is free communication around the brain-box of all the sinuses or cavities 
which contain air which have to do with the senses of smell and hearing. There 
is, furthermore, free communication between the orbit and the interior of the cra- 
nium. Infection commencing in the nose may spread to the ear by the Eustachian 
tube, to the frontal and ethmoid sinuses by means of the continuous lining mem- 
brane, or to the brain proper or its membranes by the lymphatics, whose connec- 
tion therewith has received ample demonstration. When the middle ear is filled 
up with granulation-tissue, this will form a most favorable site for the development 
of micro-organisms. The same is true of the frontal sinus when the infundibulum 
is partially closed. In both of these cavities, as in the mastoid cells, organisms 
find a closed incubating chamber most favorably located. The extension of both 
the subdural and subarachnoid spaces along the optic nerve will easily explain the 
transmission of infection from the orbit to the brain. It has only been recently 
recognized that the teeth also constitute paths of infection, and abscess in the brain 
may be found containing pathogenic organisms normal only in the human mouth. 
Furthermore, cellulitis in its various expressions may find an easy propagation from 
the scalp to the membranes, or even to the brain itself. 52 
INJURIES AND SURGICAL DISEASES OF TIIE HEAD. 
If the inflammatory process be slow, we may have localized involvement of the 
dura with extradural abscess, with perhaps adhesive inflammation, resulting in 
adhesions with the arachnoid and pia; by virtue of which a general meningitis is 
guarded against. Adhesions failing or when the infection is widespread, we have 
invasion of the whole subdural space and general leptomeningitis. Both this, as 
well as abscess, may result from thrombotic or embolic processes alone, which are 
then secondary to some similar disturbance elsewhere primary. 
There are also numerous traumatic conditions predisposing to infection, par- 
ticularly punctured wounds. Here infective thrombosis in the diploe extends along 
the perivascular sheaths to the brain. In subperiosteal abscess deep extension is 
also favored. Punctured fractures, as basal fractures, permit the introduction of 
infective materal. Even from contusions and injuries which have not produced 
fractures we may get external abscess, which may later communicate an infection 
to the interior. 
The most common of all the paths of infection is afforded by the 
middle, ear, especially when involved in a chronic suppurative lesion, 
which is by no means necessarily connected with the patulous tympanic 
membrane, and which may consequently be undiscovered, though in 
more or less constant activity. 
A. Abscess of the Brain.—This may be traumatic or non-traumatic. 
The former variety is for the most part due to the direct result of injury, 
infection displaying its consequences promptly or sometimes not until long 
periods of time have elapsed. The ordinary form occurs within the first 
two weeks, usually as an acute cortical abscess beneath a more or less 
compromised membrane, surrounded by a zone of red softening, and 
this by another of brain oedema. The chronic traumatic abscesses are 
less often cortical, but usually are deeper. They are usually marked by 
prolonged suppuration of the external wound, but sometimes occur 
through some mechanism not yet well understood. Only the chronic 
abscesses show encapsulation, the capsule partaking of the character of 
the pyophylactic membrane (see Vol. I. Chapter IX.) elsewhere 
described. It may cover a long period of time—to my personal know- 
ledge at least nine years, while others have mentioned twenty and more. 
The non-traumatic abscesses are for the most part due to middle-ear dis- 
ease. When the roof of the tympanum breaks down, it is the middle 
fossa of the skull which is infected ; when the posterior wall, naturally 
the posterior fossa. The most common results of perforation of the 
tympanic roof is involvement of the mastoid antrum or the sigmoid 
groove and sinus. In the former case we get temporo-sphenoidal 
abscess ; in the latter, cerebellar, if any. Previous to actual perforation 
there is thinning of bone with thrombosis along the minute veins con- 
nected with the sinuses. When the dura is exposed by the carious 
process, granulation-tissue often protects it against further inroads, while 
masses of the same projecting into the tympanum have been mistaken 
for prolapse. If the sigmoid groove be the site of the first disturbance, 
extradural abscess may form between the sinus and the remaining bone, 
the granulating process then involving the whole bony groove. Its later 
consequence is sinus phlebitis, sinus thrombosis, or intradural infection. 
If there be adhesion between the dura and the cortex, we get actual 
brain ulceration without formation of a true abscess; but if once the 
perivascular sheaths have carried infection to the substance of the brain, 
there is a rapid purulent disintegration of the same, and formation of a 
true subpial or deep abscess, which latter is in effect a purulent en- SEPTIC INFECTIONS WITIIIN TIIE CRANIUM. 
53 
cephalitis. Macewen has shown how important it is not merely to 
evacuate such abscesses, but to eradicate the path of infection from the 
point of origin, which is rarely easy. 
Extradural pus may escape into the mastoid cells by erosion of their 
inner walls. Such pus may escape suddenly, and serious symptoms thus 
be mitigated. Even abscess of the bone may thus empty itself by the 
process of adhesion and pointing toward the surface, but such a thing is 
most rare. Pus from the mastoid cells may perforate the tempo ro- 
maxillary joint or escape along the digastric groove and form deep cer- 
vical abscesses. 
Once the arachnoidal tissue be involved, both subdural and sub- 
arachnoidal spaces participate in the infection, and the brain floats upon 
a pus-bed rather than a water-bed. Leptomeningitis under these circum- 
stances becomes quickly diffused and fatal. Serous fluid may accumulate 
so quickly as to produce death by mere obstruction to the cerebral 
blood-vessels, while distention of the ventricles and an acute infectious 
internal hydrocephalus is possible. Leptomeningitis may be propagated 
wherever anatomical paths may carry it, even to the cauda equina and 
along the spinal nerve-sheaths. 
The pus within cerebral abscesses is often discolored, sometimes 
offensive. A greenish color is usually imparted by the bacillus pyocy- 
aneus, while the offensive odor comes mostly from the bacillus coli. 
Around every such abscess is a zone of actively inflamed cerebral tissue. 
If within this zone a pyophylactic membrane may be produced by con- 
densation, the abscess may become encapsulated and life be prolonged. 
When a capsule fails to form, the process being too acute or rapid, death 
is the speedy termination of such a case. These abscesses are for the 
most part single, but may be multiple. There is also a metastatic 
expression of abscess-formation, seen in typical cases of pyaemia 
where numerous miliary abscesses are found within the brain. Pressure- 
symptoms are less likely from abscess than from a tumor of the same 
bulk, while there is much greater liability to oedema and sudden infec- 
tion. Gradually extending paralysis implies pathological activity 
around the abscess. Large collections of pus are often met with in 
the least vital parts of the brain, as in the frontal or temporo-sphenoidal 
lobes. 
Symptoms of Brain-abscess.—Aside from causal indications (e. g. 
injury to the head, middle-ear disease, recent operations upon the air- 
containing cavities, etc.), the first symptoms may be slight. They con- 
sist usually of headache, often ascribed to cold or trifling injury, becom- 
ing exaggerated, rarely definitely located, radiating widely. In time it 
is spoken of as “ excruciating,” and may be continuous or intermittent. 
Vomiting is not infrequent, rarely accompanied by nausea. Chills come 
on early in the history of the case, varying in intensity, duration, and fre- 
quency. The more frequent, the more likely is it that the abscess results 
from some general infection. Temperature is seldom much elevated ; it 
is often subnormal. When exalted, it is in proportion to the degree of 
meningeal involvement. If pressure-symptoms become marked, we get 
the usual slow pulse due to increased tension. After evacuation of pus 
pressure-symptoms may subside, but temperature rise. Such discharge 
from the middle ear as may have been previously noted usually dimin- 54 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
ishes. A history of cessation of discharge and of increased pain and 
fever occurring at irregular intervals is very characteristic. 
These patients seldom come under the surgeon’s notice until the con- 
dition is evidently most serious. If they are still conscious, pain is the 
dominating complaint. This may he aggravated by percussion over the 
affected region. Rigidity of the sterno-mastoid on the affected side is a 
sign of lesion of the sigmoid sinus. Pain elicited by deep pressure in 
the posterior cervical triangle is also significant. There is mental hebe- 
tude, progressive failure of mental and physical power as the stupor 
increases, or coma becomes marked. 
Abscesi$ may be often distinguished from infectious thrombosis, since in 
the latter respirations are quickened and vomiting occurs when the 
patient is in the upright position. 
Vomiting accompanied by cephalalgia is always indicative of intracra- 
nial mischief. If it be a special feature throughout the case, it may 
indicate cerebellar lesion. Convulsions are also frequent, but rarely dis- 
tinctive. They are the result, for the most part, of secondary irritation 
of motor areas. Paralysis is the consequence of destructive rather than 
of irritative lesions. 
Much of value can be learned from a careful examination of the ear, 
and here the careful use of a probe will give much information. 
Localizing symptoms are only occasional in connection with cerebral abscess, 
because the majority of these lesions are located without the motor area. Pupil- 
lary alterations are indefinite. As an abscess enlarges the size of the pupil may 
increase. Infective thrombosis rarely affects the pupils, save that when located in 
the cavernous sinus it may produce ptosis. In teviporo-sphenoidal abscess pain is 
usually localized at or near the ear upon the same side. As the motor area becomes 
involved we have the gradual development of distinctly localizing phenomena, 
referred to the opposite side. Facial paralysis is common in advanced destructive 
lesions in the mastoid and tympanum. When produced by cortical lesion it is 
rarely so pronounced as when by direct paralysis of the nerve. In frontal abscess 
there are few, if any, localizing phenomena. Abscess in the parietal region is most 
commonly of traumatic origin, and is to be suspected in accordance with external 
surface markings. Occipital abscess is exceedingly rare; cerebellar abscess furnishes 
few localizing symptoms. Its most prominent clinical features are retraction of the 
head and neck; slow, feeble pulse and respiration; subnormal temperature; vio- 
lent yawning; rigidity of the masseters; slow speech ; optic neuritis; vertigo and 
vomiting. If accompanied by thrombosis, there is pain and pressure in the upper 
part of the neck. In all of these cases when abscess is near the surface there is more 
or less leptomeningitis, which becomes diffuse at once when the abscess bursts. If 
meningitis be present, we have high temperature without marked remissions, rapid 
pulse, and general irritability, rapidity of pulse indicating predominance of lepto- 
meningitis over encephalitis, since the more marked the latter the slower the pulse. 
As distinguished from sinus thrombosis, we have, in the latter, high temperature 
with marked remission, rapid and wreak pulse, frequent chills, profuse sweats, and 
often symptoms of pulmonary infarct, or diarrhoea, with cervical and submastoid 
tenderness and involvement along the jugular vein upon the affected side. If all 
three conditions be associated, the symptoms of thrombosis usually prevail, though we may 
get retraction of the head due to basilar meningitis. As between tumor and abscess 
we have in the former absence of explanation of infection, slow progress of symp- 
toms, more definite localizing phenomena, progressive involvement of nerves, pro- 
nounced optic neuritis, absence of chill, and alternating periods of mitigation of 
symptoms. Temperature and pulse afford little help, save that subnormal tempera- 
ture points rather to abscess. 
Prognosis.—From every direction come statements that the tendency 
of cerebral abscess is invariably toward fatality. No matter what the SEPTIC INFECTIONS WITHIN THE CRANIUM 
55 
cause, unless relief be promptly afforded death is the sure result. Of 
the acute cases, those not promptly operated usually die within a few 
weeks; the more chronic or prolonged cases unfortunately rarely come 
under surgical treatment. Most of those which do are the result of dis- 
ease in or about the middle ear. Were it possible to diagnose an attack 
of these abscesses early, prognosis would be much more favorable. 
When seen before necessarily fatal complications have arisen, in in- 
stances where the position can be reasonably well determined, surgical 
attack is likely to give good results. After proper evacuation even com- 
plete mental and bodily recovery is possible. Anchoring of the brain 
by adhesions may leave a train of disquieting symptoms, which, however, 
are not so bad as fatality. One must never forget that abscesses may 
remain for a long time encysted, and yet be a fruitful source of danger. 
Multiple abscesses may complicate both the diagnosis and the treatment 
and produce a condition beyond help. 
The operative treatment of these cases will be discussed by itself. 
B. Sinus Thrombosis.—The sinuses are predisposed to thrombosis 
by virtue of their size, inflexibility, shape, and the fact that they are not 
emptied during respiration; all of which tend to retard blood-flow. If 
to these be added defect in the blood-supplv, then everything predisposes 
toward marasmic thrombosis. This occurs much less frequently than the 
infective form, is mostly confined to the longitudinal sinus, is noted 
mainly at the two extremes of life, and is often seen in cases of death 
following exhausting diarrhoea in children. In the marasmic form, the 
clots are dense, firm, stratified, and non-adherent; they very rarely occupy 
the whole calibre. In the old cases the clots may be tunnelled sufficiently 
to permit re-establishment of circulation. Their principal evil conse- 
quences are oedema of the frontal lobes and sero-sanguineous effusion 
into the ventricles or orbits—in the latter case producing exophthalmos. 
Sometimes epistaxis is produced. Strabismus, tremor, muscle-rigidity 
or contractures are more often seen conjoined, especially in children, 
with convulsions, sometimes unilateral, and choked disk. 
The diagnosis in adults is difficult, but in children, when convulsions 
occur after exhausting illness with the signs just noted, marasmic throm- 
bosis may ordinarily be diagnosticated. 
Infective thrombosis, the other variety, is due exclusively to the inva- 
sion of pyogenic organisms. It is met with mostly in the basal sinuses ; 
its origin is local, and it is always secondary to some external infection. 
Its most frequent cause is middle-ear disease ; consequently, the sigmoid 
sinus is the one most often involved. It may follow carbuncle, erysip- 
elas, or cellulitis of the external parts, or nasal ulceration, as well as 
dental caries, suppuration of the tonsils, etc. Infection may be propa- 
gated by tissue-continuity or through the circulation. 
Clots form for the most part rapidly, completely occlude and quickly adhere to 
the sinus-walls; soon they begin to disintegrate, pus is formed, and the resultant 
fluid is a mixture of blood-elements and pus swarming with bacteria and tending 
constantly to enlarge the limits of the lesion. The clot frequently extends into the 
internal jugular, with production of local lesions. Outside, the smooth venous 
walls have less resistance, and there is more opportunity for dislodgement of clot. 
Purulent fluid often collects between the sinus and the surrounding bone and may 
escape by the mastoid vein. Its significance upon the exterior should never be 
minimized. So, also, it may extend along the posterior condyloid foramen and 56 
INJURIES AND SURGICAL DISEASES OF TIIE HEAD. 
produce deep cervical abscess. This pathological activity, if not too rapid, tends 
to the formation of granulation-tissue around the sinus-walls, which will extend 
into the bone as into the lumen of a vessel. It may act as a barrier and later 
organize, or it may itself rapidly break down. The terminal limits of most of 
these thrombi are protective. Thus, a cord-like mass in the internal jugular, 
beneath the sterno-mastoid, helps to protect against pulmonary infarct. 
Symptoms.—Infective thrombosis presents few distinctive symptoms. 
Local ischaemia, perversion of function, extracranial oedema are too 
vague. Headache is nearly always constant, and vomiting is frequent; 
temperature runs high with marked remissions; the pulse is small and 
rapid, and remains so even under an anaesthetic. Chills are frequent, 
are of the pyaemic type, and are followed by copious sweats. Should 
pulmonary infarction occur, we will have the typical thoracic signs, 
although at first physical examination may give negative results. Later, 
however, we get prune-juice expectoration, putrid sputum, etc. Cere- 
bral function is disturbed late, rather than early. The duration of the 
disease ordinarily is from two to four weeks. Should meningitis com- 
plicate the case, there is more violent headache, persistent high temper- 
ature, great excitement, muscle-spasm, strabismus, delirium, and coma; 
if the sigmoid sinus be involved, there is usually retraction of the head. 
Should leptomeningitis extend down the spine, girdle pains will be com- 
plained of. 
We may also have exophthalmos on one side or both, with conjunctival injec- 
tion, oedema of the lids, and disturbances of vision, due to thrombosis of the 
cavernous sinus and stasis in the ophthalmic vein. In thrombosis of one trans- 
verse sinus only the internal jugular on that side will carry less blood. So long 
as that on the other side is free, it will take that which cannot pass through the 
obstructed one. Consequently, the jugular on the other side will carry more. But 
if the contained clot extend so far that direct communication with the internal 
jugular is interfered with, then the internal jugular of the affected side will be 
almost empty, while the external of the same side will be the more distended. 
When the eye is protruded and the frontal vein distended, it is evident that the 
cavernous sinus on that side is involved. If the superficial veins of the scalp be 
distended, it is the superior longitudinal sinus which is at fault. When the veins 
of the mastoid region are involved, we may locate the thrombus in the transverse 
sinus; when there are no localizing symptoms, we can only say in a general way 
that thrombosis has occurred. 
Prognosis is always unfavorable, though recovery is not impossible. 
The therapeutics are in the main prophylactic. By actual physiological 
rest the possibility of pulmonary complications can be diminished. The 
treatment, aside from this, is purely operative, and will be discussed 
elsewhere. 
C. Sinus Phlebitis.—This may be the result— 
(a) Of thrombosis; or, 
(b) The continuation of suppurative processes from neighboring 
tissues. 
Infective thrombi produce sinus phlebitis by direct extension from 
within, as do surrounding suppurative foci from without. Acute sup- 
purations often follow vessels and nerves, and work their way along the 
connective tissues surrounding them, and thus penetrate from the dura 
into the sinus ; but for the most part the veins which empty into a sinus 
are directly responsible for its. infection. External lesions as well as 
internal furnish such infection by means of the wonderfully free venous 
anastomosis. SEPTIC INFECTIONS WITHIN TIIE CRANIUM. 
57 
In sinus phlebitis the sinus-walls are thickened and infiltrated, while 
its cavity is filled with breaking-down clot. The veins of the cortex 
and its membranes are overfilled, and extravasations often complicate 
these cases. In fact, with sinus phlebitis we often find pachymeningitis 
and leptomeningitis, and even brain-abscess. 
Symptoms.—These are seldom absolutely diagnostic. Sinus phle- 
bitis is often accompanied by meningitis, even encephalitis. The first 
symptom is usually severe headache, often localized, made worse by 
pressure. Anorexia, with early mental disturbance and often delirium, 
follows, with vomiting, restlessness, and mania, changing to stupor and 
coma. Rigidity or spasm of cervical muscles, or of those of the extrem- 
ities, followed by paralyses, is often seen. Evidences of irritation of 
special nerves, particularly the oculo-motor or the vagus, are not rare. 
When pysemic symptoms occur they are vague and are most conspicuous 
in the lungs and liver. Taken in conjunction with aggravating brain- 
symptoms, they make prognosis most unfavorable. 
Symptoms will in large measure depend upon the sinus most involved. They 
are most characteristic if this be the cavernous sinus. Here we have disturbances 
in the eye on the same side, congestion of orbital veins, pain and photophobia, and, 
later, cloudiness of the cornea and cedema with exophthalmos. Finally, the pupil 
becomes paralyzed and dilated, the cornea loses its polish, the upper lid cannot be 
raised, and, if the case persist long enough, the cornea ulcerates. Along with these 
local evidences there will be complaint of frontal pain, usually with paralysis of 
the hypoglossal nerve and consequent thickness of speech. When the transverse 
sinus is involved, we have, first, vagus irritation, then paralysis with paralytic 
sequences in the muscles of the jaw, the tongue, palate, pharynx, etc. Diaphrag- 
matic motions are interfered with and the character of the respiration altered. As 
the trouble extends to the internal jugular, we have further paralysis of accom- 
panying nerves, especially of the hypoglossal. As the irritation extends down the 
vein, we will have tenderness, rigidity, and often swelling. The local signs and 
symptoms vary obviously as the lesion extends from one sinus to the other, since 
when one cavernous sinus is involved the trouble nearly always extends to the 
other, and local symptoms are repeated upon the opposite side. 
Diagnosis.—Primary symptoms are those common to all of the 
intracranial infections. In the presence of pygemic features symptoms 
of local involvement, swelling of joints, etc., one can ordinarily elim- 
inate the pure type of meningitis. Should there be evident reason for 
deep infection, diagnosis is also simplified. Oculo-motor paralysis, ptosis, 
pupillary alterations, etc., occurring early, are of great importance. Eye- 
symptoms point primarily to the cavernous sinus, while lesions of the 
vagus or hypoglossal or glossopharyngeal nerves point to the transverse 
sinus, as do pain or tenderness over the mastoid or down the neck. 
D. Meningitis.—The dura has a duplicate anatomical character. 
Its outer surface, having the structure of periosteum, functionates as 
such; its inner surface, being lined with endothelium, partakes of the 
nature of a true serous membrane. When the former texture is 
mainly at fault, we have pachymeningitis externa, or endocranitis, which 
is rarely primary, but usually a propagated lesion met with after injury 
or external infection. It may lead to infiltration with purulent products, 
and, if speedy exit for pus be not provided, to involvement of the pia 
within. Extradural suppuration without external injury is very rare, 
but should there have been a subdural hemorrhage with external lesion, 
the blood-clot may become infected and break down. Pachymeningitis 58 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
externa is most common after chronic lesions of the cranial bones—i. e. 
caries and necrosis—and is scarcely to be separated from them. Symp- 
toms are not characteristic and often not distinguishable. When chronic, 
there will be local tenderness, evidence of the presence of pus, perhaps 
with focal symptoms. 
The treatment is always surgical, save possibly in certain cases due 
to syphilis, where delay may be justifiable for the purpose of testing 
the action of antispecific drugs. 
Pachymeningitis interna is often confounded with chronic hydro- 
cephalus. It is frequently the occasion of a firm membranous exudate 
upon the internal surface of the dura, which forms in time a new mem- 
brane rich in small and extremely friable vessels, from which hemor- 
rhages easily occur, thus giving rise to the condition of pachymeningitis 
hsemorrhagica. Trifling hemorrhages will produce little or no disturb- 
ance ; when of greater extent they may give rise to localizing brain- 
symptoms. These extravasations may absorb or undergo fluidification— 
i. e. produce localized or cystic collections of fluid. The condition some- 
times occurs after other acute infections, especially pneumonia, pleurisy, 
typhoid, whooping cough, etc. Recovery is possible, but usually at the 
expense of adhesions, which lead to subsequent complications. 
Treatment must be in a large degree surgical, since little short of 
eradication will bring about the desired result. 
The symptoms of pachymeningitis hcemorrhagica are headache, which 
will increase in intensity with every new escape of blood, usually local- 
ized in the vertex, with more or less paralysis following each new 
extravasation. The final result may be atrophy, even extensive. 
Absence of disturbance in the cranial nerves points to lesions in the 
convexity rather than basal or ventricular. In chronic cases we have 
optic neuritis, and toward the end coma, coming on for the most part 
slowly. Dennis has recommended trephining under these circumstances, 
and has practised it with great benefit. 
Leptomeningitis.—This term refers to inflammation (i. e. infection) 
of the pia mater, in whose texture we encounter tissue quite different 
from that composing the dura, and in which, when inflamed, distinction 
as between arachnoid and pia has disappeared. Leptomeningitis suppura- 
tiva is an exceedingly common expression of intracranial infection, and 
may result not merely by extension, but as a primary infection. When 
begun, it spreads most rapidly, the fluid contained within the meningeal 
cavities, mixed with pyogenic agents, helping to disseminate the active 
agents to the ultimate limits of the membranous involvement. Conse- 
quently, basilar meningitis usually extends down the spinal canal. Next 
to injury, the most frequent cause is middle-ear disease with its infectious 
complications and extensions. Next to this come sinus phlebitis and 
endocranitis. Infection from the teeth and the nasal cavity may occur. 
It is also known to result from panophthalmitis: in traumatic cases, 
when primary, it sets in early, even from four to thirty-six hours after 
injury. So rich is the pia in loose connective tissue that even from the 
outside the inflammation may assume the phlegmonous type. Thecere- 
bro-spinal fluid, as well as that of the ventricles, becomes cloudy, con- 
tains numerous flocculi, and is often blood-stained. 
Symptoms.—When the disease is limited to the vertex and follows SEPTIC INFECTIONS WITHIN THE CRANIUM. 
59 
several days after injury, it begins usually with chills and malaise, with 
increasing temperature; after which the symptoms assume the pysemic 
type, distinguished from true pyaemia by their comparatively early onset. 
The pulse becomes frequent, first full, and then small; patients are dis- 
turbed, restless, or uncontrollable, complain of headache, moan, grate 
the teeth, become delirious, with glistening eyes and congested face. 
After a while delirium subsides into stupor and restlessness into insensi- 
bility. The pupils contract and remain inactive to light. Paralyses, 
cramps, etc. are not infrequently met with. Traumatic basilar leptomen- 
ingitis occurs often with fracture of the base. Signs and symptoms are 
less distinctive here ; paralyses occur more easily and are less distinctive, 
save those which involve the special cranial nerves. When ptosis occurs 
with dilatation of the pupils, glossopharyngeal paralysis, etc., we should 
be quick to suspect extension of the process along the brain. Cramp or 
stiffness of cervical muscles means the same thing, and is a sign of very 
grave import; it may even be considered pathognomonic. Albuminuria 
is frequent, with marked increase of phosphates in the urine. 
In the non-traumatic cases the symptoms of leptomeningitis are those of 
increasing brain-pressure and temperature. The disease usually com- 
mences with headache followed by vertigo, hypersesthesia, restlessness, 
delirium, insomnia followed by somnolence, muscle-spasm, paralyses, 
coma, and death. If the disease extend from the middle ear, we fre- 
quently have facial paralysis before the meningeal symptoms appear. 
The type of fever is one of gradual increase, though before death 
temperature often falls even below the normal. Pathognomonic fever 
should not be mistaken for the elevation of temperature which often 
accompanies absorption of intracranial hemorrhages. In these latter 
cases temperature may amount to 39° C., but if rising higher than this, 
meningeal complications should be suspected. 
Diagnosis as between sinus phlebitis and leptomeningitis depends 
for the most part upon the recognition of pysemic symptoms. When 
the latter are entirely wanting, we may at least say that the predomina- 
ting symptoms of sinus phlebitis are absent. 
Prognosis is almost always bad. Many cases end in forty-eight 
hours; others may live for two weeks or more. 
Treatment seems almost futile, though one should endeavor by ener- 
getic purgation, venesection, etc. to do what he can. The only prospect 
or hope comes from the possibility of relieving the compression from 
effusion of purulent fluid, and of irrigating and draining what is now an 
enlarged abscess-cavity. Since now we do not hesitate to open and wash 
out other serous cavities when thus affected—e. g. peritoneum, pericar- 
dium, joints, pleura, etc.—we should no longer hesitate to open the dura 
and wash out the subdural space, even though this necessitate more than 
one trephine opening. The measure was suggested by S. W. Gross in 
1873, when he reported cases thus treated with success, and has since 
been practised by other surgeons, among them by Souchon, who has 
advised multiple puncture with the small drill and irrigation and disin- 
fection through numerous small openings. Of 11 cases collected by 
Gross more than twenty-five years ago, 45 per cent, recovered. 
E. Encephalitis.—The etiology of this condition is practically that 
of leptomeningitis. It may proceed from sinus phlebitis or from the 60 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
veins emptying into the sinus, infection travelling backward rather than 
forward. In many cases the primary infection occurs from without, as 
in gunshot fractures, etc. It is also transmitted along the lymphatic 
channels, since I have operated on abscess in the frontal lobe following 
intranasal operation. It assumes practically always the suppurative 
type, and may run either an acute or a chronic course. When acute, 
the lesion is usually limited in area, and the result is an acute abscess 
with irregular boundaries. 
Symptoms.—These will depend largely upon the portion of the 
brain involved and the acuteness of the process. Symptoms may even 
be almost lacking. When present, they are mainly those of brain- 
pressure, often with localizing phenomena. Convulsions with loss of 
consciousness, vomiting, slowing of the pulse, stertorous breathing, 
almost always followr a serious form of diffuse encephalitis. When 
pysemic symptoms complicate the case, they point toward a sinus phle- 
bitis as the origin of the encephalitis. These collections of pus within 
the brain may long lie latent or encapsulated, and then be suddenly 
aroused into acute activity, proving fatal by an acute dissemination with 
serous oedema; all of which will be evidenced by symptoms as given 
above. When active trouble is aroused, it is ushered in by chills, after 
which compression symptoms occur very promptly. 
Diagnosis must be made largely upon the history. 
Prognosis is always unfavorable, and treatment will depend 
entirely upon what can be inferred as to the nature and location of the 
primary cause. In most cases by the time a diagnosis is fairly arrived 
at it is too late to do anything. 
Operative Treatment of Intracranial Suppurations. 
In dealing with pus the surgeon can never follow a safer rule than to 
go according to this dictum : i. e. that pus left alone is a greater source 
of danger than the surgeon’s knife judiciously used. Consequently, 
ubi pus, ibi evaeua, applies to intracranial collections as well as others. 
For its detection and evacuation, operations are now regarded as not 
merely justifiable, but indicated whenever there is presumption of its 
presence. Discussion now hinges entirely upon the wisdom of explora- 
tion when absolutely no diagnosis can be made. But when we re- 
member the inevitably fatal tendency of these abscesses and the rela- 
tively exceedingly small danger of exploration, we may feel that there 
is at least no part of the cerebral cortex where pus may accumulate 
where it may not also be attacked with propriety. Save where an open- 
ing already exists, trephining is a necessary preliminary. Among other 
indications is spontaneous escape of pus through previous opening or any 
of the natural outlets of the cranium, with or without localizing phe- 
nomena. Further indications are those pertaining to the bone—i. e. loos- 
ening of pericranium; or to the scalp—i. e. oedema, puffy tumor, etc.; 
and certain other indications are those of a more general character, chills, 
pyrexia, etc. When the dura is exposed, much can be judged of by 
the existing brain tension, it Being now well established that brain 
pulsation is often characterized by the presence of pus beneath the dura. 
The most feasible method for detection of subdural or deep collections OPERATIVE TREATMENT OF INTRACRANIAL SUPPURATIONS. 
61 
is by the use of the aspirating needle—a method now generally in vogue 
and everywhere accepted. 
In most of the suppurations connected with middle-ear disease will 
come up the question whether to open the mastoid antrum, the mastoid 
cells, or the brain-cavity proper. Indications for the first of these are 
—history of repeated mastoid swellings and tenderness, acute inflam- 
mations, with soreness or retention of pus in the region of the mastoid, 
purulent otorrhoea, with beginning symptoms of intracranial mischief, 
or persistent otorrhoea with offensive discharge, which may long exist 
without mastoid swelling. The mastoid may be attacked through the 
suprameatal triangle of Macewen, formed by the posterior zygomatic 
root and the upper and posterior segments of the external osseous 
meatus. After opening it with revolving burr or with the chisel, the 
surgeon must determine the position of its communication with the 
middle ear and that of the facial canal, the occurrence of facial twitch- 
ings often announcing the proximity of the surgeon’s instruments to the 
facial nerve. The middle ear may be opened by extension of the burr- 
ing process along the outer wall of the antrum to the junction of its 
roof. Through this opening the malleus and incus may be removed, 
and should be if diseased; the stapes should be left if possible. 
Temporo-sphenoidal abscess will often be indicated by the escape of 
pus through the dura above the roof of the tympanum. It may per- 
haps be evacuated by enlarging this approach to it, though ordinarily 
it would be much better to trephine above the ear and remove all the 
sloughs of brain-tissue. If the mastoid be also involved, the incision 
for opening the antrum may be extended upward two inches, and the 
centre pin of the trephine placed three-quarters of an inch above the 
posterior root of the zygoma. After exposing the dura its appearance 
should be noted. If it be normal, the course of the pial vessels may 
be discovered through it. Here, again, the use of the aspirating needle 
will be most serviceable. Abscess once discovered should be freely 
opened, diploe removed, and the cavity carefully irrigated. After 
thorough cleansing, drainage-tubes are of little, if any, use. Gauze 
packing is by all means the most serviceable. This would necessitate 
the employment of secondary sutures, or perhaps the leaving of the 
external wound open from the fundus in order to permit removal of the 
gauze. 
In operating upon the sinuses it is best to amply expose the sigmoid sinus, the 
incision for this purpose extending from the tip of the mastoid to the posterior 
root of the zygoma. From the posterior extremity of the parieto-mastoid suture 
a line drawn to the tip of the mastoid overlies the course of the sinus. Opening 
should be made on the level of the bony meatus. The overlying bone varying 
much in thickness, the surgeon should proceed with great caution. In the course 
of operations necessitated by middle-ear disease this sinus is usually exposed, and 
the antrum has been opened when sufficient reason for the condition is not therein 
discovered. After exposing the posterior wall of the antrum the bone is opened 
behind it for half an inch. If in the sigmoid groove granulation-tissue or pus be 
found, the surgeon should again proceed with great caution. He should expose 
much more of the sinus-wall and remove all diseased bone in the locality. Every- 
thing outside of the sinus should also be disinfected before it is opened. After 
incising it and cleaning out its purulent contents it should be packed with gauze. 
Hemorrhage is practically always under control by tamponing with gauze. 
Should the internal jugular vein be felt filled with thrombus or distended, it 
should be exposed in the neck below the contained clot, ligated, and either split 62 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
open or irrigated through, so that communication is free between it below and the 
sinus above. When one can foresee that this may be necessary, it is wise to 
operate upon the vein first. 
Operation for relief of purulent meningitis has already been suggested. In the 
absence of definite indications or of opening, the best point for operation is that at 
which the meningeal cavity may be properly drained. Opening should be, accord- 
ingly, made below the superior curved line of the occiput or just above the supe- 
rior border of the posterior part of the zygoma. It may also be well to open well 
down in the cervical region. The arachnoid space must also be opened. Souchon’s 
method of exploration with the ordinary bone-drill, whose point is carefully guarded, 
and the employment of numerous openings with exploration by the fine aspirating 
needle, may be put in practice when indicated. 
Cephalocele. 
The term cephalocele is applied to tumor of the endocranium pre- 
senting through defects in the cranial bones, of essentially congenital 
origin, and containing more or less of intracranial contents. It com- 
prises— 
A. Meningocele ; which means a tumor consisting of a membranous 
protrusion and containing cerebro-spinal fluid ; and, 
B. Encephalocele ; referring to tumors which contain also more or 
less of actual brain-substance. 
Such tumors of non-traumatic origin can only be explained by the existence 
of congenital defects which permit the escape of that which the normal bone retains 
within normal limits. In most instances the defect is in the middle line, at either 
one or the other extremity of the skull. In some instances the arches of the atlas, 
or even of other cervical vertebrae, are lacking. The most common cephaloceles 
are the occipital, which are known as inferior when below the occipital spine, or 
Fig. 14. 
Defeet in cranium permitting sincipital cephalocele (Bruns). 
superior when above it. Those appearing anteriorly are known as “sincipital,” 
and are met with most often at the root of the nose, where they may communicate 
with the orbit or the nasal cavity. Other and irregular forms are laterally or 
unsymmetrically located. Thus, we may have naso-l'rontal, naso-ethmoidal, etc. 
Still another group of cephaloceles escape through fissures or defects at the base 
of the skull, and, sinking between the ethmoid and sphenoid, present in the naso- CEPHALOCELE. 
63 
pharynx. Thus we may have naso-pharyngeal, spheno-pharyngeal, spheno-orbital 
and spheno-maxillary cephaloceles. These tumors are for the most part single, and 
vary in size within wide limits. For the most part they have an even shape and 
surface, yet are occasionally divided by folds or constrictions. Many of them have 
a pedicle much smaller than the tumor itself; others are spread bodily upon the 
skull. The overlying integument may be very thin, reddened, and vascular, even 
to such an extent that the tumors are mistaken for angeiomata, or it may be so 
metamorphosed and thickened as to divert suspicion of their actual character, 
even to imitate lipomata. 
Cephaloceles have an elastic feeling, many of them an exquisite fluc- 
tuation. Sometimes by touch alone we recognize both their fluid and 
Fig. 15. 
Occipital cephalocele (original). 
solid contents. A meningocele with thin walls is translucent. By pres- 
sure they can be reduced in size, such pressure producing usually brain- 
symptoms, often paralysis or convulsions. Many children thus affected 
cannot lie upon the tumor without becoming restless. When the little 
patients cry or make any violent straining efforts, the tumor becomes 
larger and its covering more vascular, while during qniet sleep it is 
usually reduced in size or tension. 
Fig. 16. 
Sincipital meningocele (original), 
A large proportion of patients with these congenital defects die shortly 
after birth. The tumor, when large, may be ruptured during delivery. 
Occasionally the sac ruptures spontaneously, which accident is usually 64 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
followed by purulent meningitis from infection, though it may possibly 
lead to spontaneous recovery. The principal danger always is of such 
accident. 
The encephaloceles are divided into the cenencephaloceles, contain- 
ing solid brain substance, and hy dr encephaloceles, consisting of the pro- 
trusion of a dilated brain-cavity—i. e. a thin area of brain enclosing fluid 
communicating with one of the ventricles. Most of the large tumors 
pertain to the latter class. The more brain material such a tumor con- 
tains the more does it pulsate, especially if the patient cry or strain ; the 
smaller, too, is the skull—i. e. the greater the tendency toward micro- 
cephalus. 
As between the different forms of cephaloceles, diagnosis is usually 
not very difficult. Pure meningoceles are most common in the occipital 
region; they are translucent, are easily reduced in size by pressure, and 
are readily emptied by aseptic puncture. The hydrencephaloceles form 
large fluctuating tumors, often somewhat translucent, symmetrically 
developed, for the most part occipital in location, not reducible, and but 
slightly influenced by full expiration. They are most common in con- 
nection with deformed skulls. The cenencephaloceles are probably the 
only variety which persists to adult life. They are, for the most part, 
anterior; may have thick walls; are only partly reduced in size by punc- 
ture ; pulsate with violent exertion ; diminish during sleep; and are only 
slightly reducible. 
Treatment.—Treatment should, first of all, be protective, by a 
shield of some device held in place by a suitable bandage or dressing. 
Compression, with or without puncture, has given the most generally 
satisfactory results, but not much should be expected from any method 
or combination. Most of the cases are such that extirpation woidd seem 
applicable, but the impossibility of absolute asepsis in young infants and 
the liability to fatal shock preclude most of these attempts. In some 
instances ligature of a meningocele has been successfully applied. In 
time, injections, as recommended in spina bifida (which see), may also be 
resorted to. Operation may be attempted in young children with sincip- 
ital encephalocele. Plastic operations may be resorted to, or plastic 
manoeuvres combined with extirpation. It may be possible by the inser- 
tion of a celluloid plate to atone for a small defect in the skull after ex- 
tirpation of a tumor of this kind. I have successfully practised this 
method in spina bifida. 
Hydrocephalus. 
This term is applied to abnormal collections of cerebro-spinal fluid 
within the cranial cavity. We speak of— 
A. Hydrocephalus ventriculorum or internus, when the fluid is 
confined to the dilated ventricles of the brain; or of— 
B. Hydrocephalus mening-eus or externus, when the fluid collects 
between the brain and the dura. 
The former condition is much the more common. The cause of 
hydrocephalus in the young .is essentially congenital, and inseparable 
from imperfect development within the cranium. The forms are occa- 
sionally combined. At the time of commencing trouble the skull may HYDROCEPHAL US. 
65 
be of natural size, but yields to the accumulation of fluid within, until it 
attains relatively enormous dimensions. Most children thus affected die 
early, some shortly after birth. It is most common in rachitic children. 
Hydrocephalus developing in the adult is the result almost solely of atro- 
phy of the brain. Pachymeningitis interna (see pp. 58 and 66) may also 
produce subdural exudate leading to hydrocephalus externus. Encapsu- 
lated collections of cerebro-spinal fluid due to pachymeningitis interna 
are known as hygromata of the dura. A ventricular form of hydro- 
cephalus may also result from meningitis and tubercular disease. The 
condition is essentially chronic, the fluid collecting in the dilated lateral 
ventricles, though the third or fourth are sometimes also distended: 
4000 c.c. of cerebro-spinal fluid have been found in more than one 
instance. As the result of the presence of the fluid there is atrophy of 
brain, with arrest of development, to such an extent even that the hemi- 
spheres are changed into great sacs, being merely spread out upon the 
outer wall of cystic cavities ; all the surface markings are lost, and gray 
and white substance are scarcely to be differentiated. 
For the cranium itself the bones of the vertex separate, and instead 
of sutures we have a tightly-stretched membrane. There is also con- 
genital or acquired aplasia—i. e. absolute defect of bone between dura 
and pericranium. All these changes give to hydrocephalic heads a dis- 
tinctive appearance. Other developmental defects—hare-lip, club-foot, 
etc.—are common in these patients. Many infants thus affected die dur- 
ing delivery unless skilful help be at hand. The resulting disproportion 
between the enlarged head and the small face is most distinctive. Chil- 
dren in this condition suffer from disturbed digestion, are emaciated, with 
rachitic curvatures of the long bones; special senses are seldom devel- 
oped perfectly; strabismus and nystagmus are frequent, while cramps, 
stupor, etc. are by no means infrequent. 
Prognosis.—While spontaneous recovery is possible, as already 
stated, the tendency is always toward fatality. 
Treatment.—Operative treatment consists either of compression of 
the enlarging skull by bandages or their equivalent, or the removal of 
fluid by aspiration, with or without permanent drainage. Compression 
offers very little prospect of success. Moreover, there is always danger 
of pressure-sores or even gangrene. Tapping for hydrocephalus is an 
old operation long discontinued, but recently revived. The establish- 
ment of permanent drainage is a recent suggestion. When effusion has 
been rapid, puncture may be resorted to, but in the most chronic cases 
drainage seems to be the only promising measure. This, however, is 
made of extreme hazard by the impracticability, almost the impossibility, 
of maintaining asepsis, though not per se a dangerous operation. In 
puncturing or draining it is wise to avoid the motor zone and the neigh- 
borhood of the principal arteries. Perhaps the most serviceable point 
at which to trephine, preparatory to puncture or drainage, is about 3 
cm. behind the external auditory meatus and the same distance above 
the base-line of the skull. By directing the puncturing instrument to a 
point on the opposite side, 6 cm. above the meatus, the lateral ventricle 
will be entered. (The same direction may be of service in opening an 
abscess in the temporo-sphenoidal lobe.) While the results of this 
method have been so far very discouraging, it is, nevertheless, the best 66 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
which presents, save in certain instances where we tap the cerebro-spinal 
canal at its lower extremity. Lumbar puncture is a suggestion of 
Quincke, and is made between the third and fourth lumbar vertebrae, 
the patient’s body being bent forward while it is made. Puncture here 
may be temporary or permanent drainage may be resorted to. It is a 
safer procedure than cranial puncture, is applicable both for diagnostic 
purposes and treatment, and is more likely to give good results. 
The Cerebral Membranes. 
The purpose of the dura is to serve as an internal periosteum and as a distinct 
covering for the brain. It has not only a duplicate purpose, but a duplicate ana- 
tomical character, its inner surface being lined with endothelium, while its outer 
surface is densely fibrous. Accordingly, we may have pachymeningitis externa and 
interna. The external variety is usually the result of extension of trouble from 
the overlying bone—i. e. from caries and necrosis—as the result of which the mem- 
brane thickens and its outer surface becomes covered with granulations, while pus 
may form between it and the bone, and thus be for a long time shut off from access 
to parts within. Such collections are known as extradural abscesses. Their 
symptoms are not characteristic, but will include local tenderness, febrile symp- 
toms, and perhaps focal symptoms. Their treatment is that necessitated by the 
overlying lesions. 
Pachymeningitis interna is often confounded with chronic hydro- 
cephalus externus, to which it may lead. It is characterized by a mem- 
branous exudate, at first separable from the dura, to which new layers 
may be added, which becomes richly vascularized and viable, producing 
a condition in which hemorrhages, minute or serious, are frequent. 
When a small hemorrhage occurs between the membrane proper and 
this adventitious structure, we have a condition often spoken of as haema- 
toma of the dura, sometimes giving rise to localizing brain-symptoms. 
These extravasations may absorb or undergo fluidification or cystic 
degeneration, producing the so-called hygromata of the dura. These 
lesions occur for the most part upon the convexity rather than at the 
base. The condition often occurs after acute disease, and is manifested 
by headache, vertigo, mild delirium, pupillary alterations, and cramps in 
the extremities. It occurs in both the young and the old. Recovery 
is quite possible, but often at the expense of adhesions. Pachymeningitis 
hcemorrhagica is characterized by new formation of connective tissue 
upon the inner surface of the dura, this new tissue increasing in amount 
and becoming vascularized from the dura. With lapse of time it may 
form layers similar to those observed in aneurismal sacs. Hemorrhage 
from the more recently formed vessels often occurs, and clots an inch or 
more in thickness may result, which by their bulk cause serious com- 
pression symptoms. These lesions occur for the most part over the 
cortex, and when long existent may result in formation of cysts. The 
symptoms are vague, consisting mainly of headache, intensified with 
every new escape of blood, and, later, of paralysis, a study of which 
may reveal the site of the lesion. Gradual atrophy of one or both 
hemispheres may result. The pupils are usually contracted and immo- 
bile until compression is pronounced, when they dilate. In old cases we 
have optic neuritis; coma may’be the result of fresh bleeding. Dennis 
has paid special attention to these symptoms, and has urged trephining 
and exploration for the purpose of revealing the presence of a blood- THE CEREBRAL MEMBRANES. 
67 
clot and practically effecting its removal, if present. He has reported 
nine cases, some of which amply demonstrate the value of the procedure 
in cases previously doomed. 
Leptomeningitis.—This is often of the suppurative type, and results 
not merely from extension by continuity, but is often primary, or may 
be due to the breaking down of gummata, etc. Once existent, it spreads 
rapidly, the infectious agents having free access to the entire extent of 
the membrane along which they travel, even down to the end of the 
spinal cord. Its most frequent cause is disease of the middle ear, the 
infection spreading along the facial or auditory nerves. It is also often 
due to a sinus phlebitis and endocranitis—i. e. pachymeningitis externa— 
or it may spread from the nasal cavity. Prognosis is always bad. Many 
cases terminate in forty-eight hours; others may extend over two weeks. 
The general propriety of operations upon the cranium, for meningeal 
infections is now well established, but is too often made a forlorn hope 
when there is little or no possibility of any help. Could the operation 
be done earlier, in proper cases it would often be brilliantly successful. 
It is based upon the same principles which lead one to open other serous 
membranes when similarly infected. This requires of course the pre- 
liminary use of the trephine, perhaps at several points, with irrigation 
of the meningeal cavity, the establishment of drainage, etc. While 
always an operation of great gravity, it can never be more serious than 
the condition which may call for it. 
Surgical Treatment of Defects of Intracranial Develop- 
ment. 
There are numerous causes which produce imbecility- and kindred 
conditions in the young. Some are in effect congenital, some are post- 
natal. Within the past few years a number of these cases have been 
subjected to surgical operation, in many instances with more or less 
success; in a few with brilliant results. Mental defect may occur from 
injuries at the period of birth—mainly hemorrhages, for the most part 
cortical, though sometimes deep. In either case the clots thus formed 
frequently undergo cystic alterations. The term porencephalon is 
modern, and applied to changes comprising disappearance of real nerve- 
tissue with partial substitution by connective tissue, often with other 
degenerations, the result being atrophic alterations which apparently 
permit of no remedy. In a case of true porencephalon the outlook for 
operation is not at all encouraging, nor is it in any cases which are 
accompanied or caused by a genuine arrest of cerebral development. 
On the other hand, when the mental condition can be ascribed to the 
result of injuries, to hemorrhages, to meningeal irritation, to premature 
ossification, or too early closure of the fontanelles, or when it is accom- 
panied by evidence of meningeal irritation or any symptoms which 
point to a definite area of the brain as being the site of the principal 
disturbance, operation as a legitimate experiment may be conscientiously 
suggested and carried out. 
These operations have now been sufficiently tested during the past six or eight 
years to permit of certain generalizations, which are practically thus epitomized 
above. Even if epileptiform attacks are diminished in frequency, or mental irri- 68 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
tability and continuous crying relieved, if local paresis disappear or optic neuritis 
seem to subside, if the athetoid condition may be diminished or spastic contrac- 
tions relieved (all of which things have been accomplished in various cases),— 
these of themselves will justify the attempt in any case which may seem at all 
promising. On the other hand, the outlook for imbecile or idiotic children is so 
unpromising, and the undesirability of prolonging their lives so self-apparent, that 
even a large percentage of mortality should not prevent the surgeon from offering 
such prospect as he may by operative measures. If one such child be made self- 
supporting or redeemed from hopeless imbecility by such operation, it would be no 
loss, but a relative gain to humanity, should nineteen similarly affected children 
perish in the attempt to produce this result. This, at least, is my own view of the 
subject. In accordance with the view, thus expressed, I have operated in nearly 
twenty cases with a mortality of about 25 per cent, and complete failure to obtain 
any improvement in about 88 per cent., while in the remainder of the cases more 
or less improvement, varying from slight to complete restoration to health, has 
been obtained. 
The operation is usually described as craniotomy or craniectomy, 
and is apt to be successful in many cases of microcephaly combined with 
idiocy. An acquired form will give a better prognosis than will the con- 
genital condition. The danger of the operation is often great, and espe- 
cially so since it is called for in puny, ill-nourished, and badly-cared-for 
children. To be successful it ought to be extensive. It should vary in 
character and degree—from simple division of the skull along the middle 
line, from near the root of the nose to the occiput on one or both sides, 
to the formation of large bone-flaps by cutting away a wide groove of 
bone so as to relieve pressure upon the hemispheres. The accompany- 
ing figures will present the various ways of performing the operation. It 
Fig. 17. 
Lines of removal of bone as practised by the author, by Lannelongue, and by others, 
can usually be made bloodless, or nearly so, by an elastic tourniquet 
around the skull. The incision in the skin should not correspond to the 
groove in the bone, but should overlap it some little distance. For my 
own part, I prefer to do most of these operations in two sittings. I 
would advise, as a rule, to prepare the scalp carefully for operation, to 
divide the skin along the proposed line, separate it from the pericranium 
and check all oozing, packing the longitudinal wound with gauze and 
putting on suitable dressings, and waiting a few days or until the child 
has sufficiently recovered from the shock of the first operation before SURGICAL TREATMENT OF EPILEPSY AND THE PSYCHOSES. 
69 
doing the second; then, at the second operation, after opening the skull 
with the trephine, to cut away with proper forceps (rongeur) along the 
desired line, or, if provided with it, to remove the bone by some surgical 
engine or revolving saw actuated by electricity. The strip of bone thus 
removed should be at least half an inch wide, and the overlying peri- 
osteum should be removed with it, since only in this way can the unde- 
sirably rapid regeneration of bone be prevented. By this means the 
dura is exposed, but not opened. In many cases this will be enough. 
In many others, however, it will be insufficient; and, could this be 
foreseen, it would be well to combine the above measures in one as a 
first operation, and then, a week or two later, to take out the gauze pack- 
ing and open the dura as the second procedure—this, however, only on 
the discovery by careful inspection that the wound is absolutely free 
from possibility of infection. Could infection be prevented, this is cer- 
tainly the safer procedure, since in young children to make a long scalp 
incision, to remove a long strip of bone, and then to widely open the 
dura is more than can be safely done in the majority of instances. 
It should have been carefully explained to those interested in the case 
that improvement will in all probability be extremely slow, and that 
little or nothing is to be expected at first, even if prompt recovery from 
the operation ensue. Neither would I advise any one to perform the 
operation unless parents are willing to assume all risks and abide by the 
results. 
SUKGICAL TkEATMEXT OF EPILEPSY AND THE PSYCHOSES. 
Operations for relief of epilepsy seem to date back even to the pre- 
historic era, and were for centuries done as a purely empirical measure; 
later, to have been practised with more or less plausible reason ; then to 
have fallen into discredit for long periods of time, with occasional re- 
vivals of the practice, until within the past ten or fifteen years the ope- 
ration has been again revived upon its merits and upon the recognition 
of more or less accurate indications. 
Operations of this character are based upon two fundamental facts : 
the first, the widespread experience that after various operations epilep- 
tic patients have been benefited; and, second, that a certain proportion 
of these cases, especially those of traumatic origin, are characterized by 
a localized and definite aura and by a systematic and practically invari- 
able order of muscle-involvement, according, it would seem, to some fixed 
law, and pointing definitely to a certain area of the brain from which 
apparently the irritation arises and spreads. This form of epileptic seiz- 
ure is that generally known as the Jacksonian, and is that in which ope- 
ration is most often of real service. 
In spasms of the Jacksonian type there is a certain order of progression 
which is scarcely ever violated. Thus, irritation beginning in the leg 
centre cannot reach the face centre without traversing that of the arm. 
It is possible also to have sensory equivalents for Jacksonian attacks, as 
when they commence with peculiar sounds indicating irritation in the 
centre of hearing, or with optical phenomena, or with disturbances of 
smell or taste, the former indicating occipital irritation, the latter irrita- 
tion in the temporo-sphenoidal region. 70 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
The surgeon will often be consulted as to the wisdom of operation in 
the presence of this condition. In brief and in a general way, the fol- 
lowing statements may be made : It is necessary, first of all, to establish 
a traumatic origin, and epilepsy which has preceded a severe head injury 
can in no sense be ascribed to it. If it can be clearly established 
that it has followed injury, and if a distinct scar—especially a scar 
which is adherent—or depression can be discovered, or any area which 
is always irritable and which seems epileptogenic when irritated ; or if, 
again, by close study of the case it can be determined that the aura and 
the initial muscle-symptoms arise always in the same part—as, for in- 
stance, a finger, thumb, foot, etc.—and proceed according to a constant 
programme,—then one may say that operation is not merely justifiable, 
but advisable. On the other hand, when neither distinct scar nor dis- 
tinct history of localizing phenomena can be obtained operation should 
be attempted, if at all, absolutely as an experiment—an experiment 
which may be followed by good, yet one which gives little if any 
promise. 
Again, in epilepsy of the non-traumatic type, operation may be 
advised wrhen it assumes the distinctly Jacksonian form—i. e. when 
everything points to irritation proceeding from a localized portion of the 
brain. In the absence of Jacksonian symptoms operation is even more 
of an experiment than in the traumatic form. 
The operation itself is directed to excision of irritable scars, to 
exposure of the dura at the point of opening, to the detection and suit- 
able treatment of depressed fragments, dural adhesions, tumors, foreign 
bodies, etc. It is essential in every case that it be represented to those 
interested that the operation itself removes the cause, but cannot be, per 
se, expected to complete the cure, especially in cases of long standing, and 
that the final cure must depend in large measure upon the avoidance of 
subsequent irritation, upon the establishment of perfect habits of diet 
and excretion, which are often perverted, and perhaps upon the long- 
continued administration of drugs, of which the bromides are those most 
constantly given, perhaps with borax. The reader need not be reminded 
that old cases are the least favorable, and that recent cases are the most so 
for operation, and that the longer the diseased condition has existed the 
harder it will be to cure by any method. 
I believe thoroughly in operating in selected cases. I am equally con- 
fident that indiscriminate operation must lead only to disappointment 
and to occasional disaster. In the presence of long-standing lesions, 
like bone depressions, cystic degeneration of old clots, etc., the brain 
may have been so long pressed upon as to have become atrophied. 
The w'liole subject of the modern surgical treatment of epilepsy is 
inseparable from the topic of prompt and efficient treatment of all head 
injuries. Were the indications in these always met at the time of the 
accident, we should have a much smaller proportion of cases of traumatic 
epilepsy. 
Inasmuch as one object of many of these operations is to break up adhesions 
between the dura and the pia, one. is naturally anxious to know the result after 
such operations as to whether they do not speedily form anew. There is always 
this theoretical danger, and it is my custom in such cases to insert beneath the 
dura, at the point where such adhesions have been divided or torn, a piece of deli- INTRACRANIAL TUMORS. 
71 
cate gold-foil, duly sterilized, in order that it may separate these surfaces and pre- 
vent the recurrence of the old condition. Foil used for this purpose is perfectly 
harmless, and I have numerous patients in whom it has been used, apparently with- 
out producing the slightest disturbance. 
Mental and psychic disturbances after head injuries have been 
long known, and the suggestion to operate upon the skull in cases of 
so-called traumatic insanity is not new. In a general way, it may be 
said that whenever distinct mania follows a recognized lesion of the ver- 
tex of the skull, and fails to subside within a reasonable time and under 
proper treatment, there are the best of reasons for raising the scalp, tre- 
phining, and exploring as to the deeper condition. Patients might be 
redeemed from asylums who have long been inmates had this measure 
been practised at the beginning of their mental alienation. 
The same measure will give relief in certain cases of cephalalg-ia, 
or headache, where the pain is always ascribed to a particular region, 
and especially when there is tenderness over this region. These ope- 
rations are, of course, empirical, yet as the result of altered nutrition 
and allayed irritation, relief follows in a fair proportion of instances. 
Intracranial Tumors. 
Until within a few years these were regarded as having interest 
mainly for the pathologist and clinician, but as essentially hopeless so 
far as surgical help was concerned. Recent discoveries in the field of 
cerebral localization and recent experience with extensive openings into 
the cranium have shown, however, that a small proportion of intra- 
cranial tumors are of such a character and so located as to make them 
amenable to surgical relief. These tumors occur with about equal fre- 
quency in childhood and adult life. In the order of frequency they 
stand about as follows : Tubercular gumma, glioma, sarcoma, cysts, car- 
cinoma, and syphilitic gumma, with a small proportion of fibroma, etc. 
The gummata, either tubercular or syphilitic, are more common than all the 
other varieties put together. Cystic tumors may be the result of changes in previ- 
ous blood-clots or may be of independent origin. Parasitic cysts are in this coun- 
try exceedingly rare. Gumma pertains mostly to adults. Glioma is the most 
vascular of intracranial tumors, consequently has more of the erectile character, 
and may vary in size at different times. When there are marked variations of 
intracranial pressure there may be good reason for diagnosing glioma. The tumors 
most suitable for treatment are those which are firm, more or less encapsulated, 
non-vascular, and placed either on the dura, on or beneath the cortex, and in the cere- 
bral hemispheres. Tubercular tumors are seldom encapsulated, and about them there 
is usually a zone of infiltration which constitutes a dangerous area. Dermoid 
cysts may occur inside the cranial cavity, as well as outside. They are naturally 
of congenital origin, increase very slowly and insidiously, and are seldom pro- 
ductive of symptoms or signs. Tumors arising from the meninges may press upon, 
and later secondarily involve, the brain beneath, and are in most respects indis- 
tinguishable from tumors of the brain proper. These give rise to localizing symp- 
toms when pressing upon the motor and sensory centres. In other cases there will 
be vague complaint of pain. 
Of 100 cases of brain-tumor selected at random, not more than 5 to 
7 per cent, are so placed as to justify surgical attack. In as many more 
at least the tumors are so located as to justify opening the cranium for 
mere relief of pressure without any notion or endeavor to attack the 
tumor itself. Before opening the cranium diagnosis should be made as 72 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
carefully as possible—first, as to location ; second, as to whether cortical 
or subcortical; third, as to the number of tumors present; and, fourth, as 
to their general character. Location is determined in the main by study 
of pain complained of, by watching patients during convulsive seizures, 
by determining the extent of local or general paralysis, by careful his- 
tory which shall reveal the method and rate of extension of these symp- 
toms, and by the study of the optic disks, of vision, and by noting the 
presence or absence of stupor, nausea, coma, slow pulse, or other com- 
pression symptoms. 
Tumors in the sensory zone affect vision and speech, and reveal 
themselves largely by irritation symptoms. For instance, a patient 
with verbal deafness and marked hemiplegia probably has tumor in- 
volving the left superior or dorso-temporal gyrus, which, as it grows, 
would involve loss of muscle-sense and anaesthesia on the opposite side 
of the body. A patient with headache, vomiting, choked disk, stupor, 
increasing hemianaesthesia, lateral hemianopsia, without spasm or hemi- 
plegia, probably has a tumor in the white substance of the occipital lobe. 
If hemianopsia alone be present, there is almost always a tumor upon the 
inner aspect of the occipital lobe on the side opposite to the dark half- 
fields, which by downward growth may cause cerebellar symptoms. 
As to depth and number, the former may only be made out by study- 
ing the nature and location of the signal symptoms, the presence and 
order of appearance of the same, presence or absence of headache, and 
local changes in temperature. Tumors occurring in tubercular indi- 
viduals are probably multiple. When different centres or systems are 
involved we have also probably multiple lesions present. 
It has been generally held that the three cardinal symptoms of brain- 
tumor are optic neuritis, headache, and vomiting; and, while each of 
these is significant, and all of them are corroborative, they are not 
necessarily present nor does their absence exclude possibility of tumor. 
Other signs indicating the presence of tumor, it is a mistake to trait for the 
development of these three. The most distinctive feature of all intra- 
cranial neoplasms is the progressive character of such symptoms as are 
present. 
There is but one form of brain-tumor which is amenable to internal 
treatment—namely, syphilitic gumma; and in case of doubt it may be 
justifiable to keep the patient actively under the influence of iodides for 
a reasonable length of time. This, however, need never be prolonged 
far beyond two months. Should no improvement occur, to wait longer 
than this will diminish the benefit of surgical operation. 
Operation.—Brain-tumors are operated for two purposes: first, for 
relief of pain and other distressing symptoms in incurable cases; and, 
second, for radical cure if it may be achieved. Operation is justifiable 
in any case where pressure-symptoms become severe, particularly so 
when pain is localized to a reasonable extent. Choking of the optic 
disks is not infrequently relieved and threatened disability postponed. 
The operation when practised consists in, first, the exposure of the 
tumor; and, second, in its removal if possible. 
The tumor may be exposed by any of the methods to be dealt with below, the 
most serviceable probably being the osteoplastic method, by which a bone-flap is 
raised, along with the overlying scalp, from which it is not detached. The centre OPERA TIONS UPON THE CRANIUM. 
73 
of this flap is supposed to be calculated to overlie the centre of the deep lesion 
which it is proposed to attack. In many instances it is well to divide the opera- 
tion into two distinct procedures, the first consisting in removal of the bone and 
exposure of the dura; the second, a week or two later, comprising the balance of 
that which is to be done. But comparatively little shock attends removal of the 
tumor in the second stage of such a divided operation. After exposure of the 
tumor its cavity is best packed with a gauze tampon after prompt ligation of all 
bleeding vessels within the field of operation, although it is usually required merely 
on account of venous oozing, since it is often possible to cut to the depth of an 
inch in the brain without a single artery spurting except those in the pia. The 
tampon is of value if allowed to remain for forty-eight hours, as preventing filling 
of the cavity with clot or excessive bleeding during the vomiting which may follow 
the administration of the anaesthetic. In various brain operations I have been led 
to value highly the styptic properties of antipyrine, which I use ordinarily in 5 
per cent, solution in sterilized water. I have no hesitation in spraying this upon 
the brain or in saturating tampons with it, which may be left in situ so long as 
necessary. A number of the old-fashioned small serrefines, properly sterilized, can 
also be resorted to, if needed, for securing vessels which may not be easily tied. 
They can be left in place along with the tampon until the third or fourth day, 
when all may be removed together. 
Next to the danger from hemorrhage is that of rapid oedema of the brain, 
which may result from increased tension in the arteries or through venous stasis, 
which later produces lymph-stasis, by which fluid collection in the tissues is still 
further facilitated. Another reason for using tampons is to prevent such relaxa- 
tion of veins as may predispose to this oedema. In most respects the operations for 
removal of brain-tumors differ little, if at all, from those whose general principles 
are elsewhere enunciated in this work. I am greatly in favor of using secondary 
sutures (i. e. those tied with bow-knots), which may be loosened on the second or 
third day, permitting the raising of the flap, removal of tampon, etc., and I employ 
them largely after all sorts of operations upon the cranium. It is my custom often 
to saturate the tampons which lie between wound-edges with an ointment com- 
posed of sterilized vaseline to which is added 5 per cent, of naphthalin. If this 
be placed between the raw surfaces, it prevents such union between them as will 
produce oozing when they are separated again for removal of the gauze. Or, 
instead of the gauze used for this purpose, we may employ the green-silk protec- 
tive introduced by Lister, which should have been previously carefully sterilized 
by soaking in strong antiseptic solution. 
Operations upon the Cranium, 
Memoranda in Cranial Topography.—The thickness of the skull varies greatly 
in different individuals or even in the same person. The very young and the aged 
are not provided with diplo'e; hence extreme care must be exercised in perforating 
their skulls. The skull is also thinner over the sinuses and the meningeal grooves. 
The middle meningeal artery enters through the foramen spinosum and divides 
into two branches; the anterior, that most often injured, passing across the anterior 
inferior angle of the parietal bone; the other passing nearly horizontally across 
the squamous bone. It is most often lacerated at the parietal angle. The frontal 
sinuses in many individuals are capacious, and by them in the naso-frontal region 
the tables of the skull are somewhat widely separated. 
The fissure of Rolando is the anatomical landmark whose position it is most 
important to determine with reference to a number of modern surgical procedures, 
since around it cluster most of the motor areas or centres. It commences at the 
middle line, about 56 per cent, of the distance backward from the glabella (root 
of the nose) to the inion (occipital protuberance), and, passing downward and for- 
ward, makes with the middle line an angle of 67° to 69°. For most purposes it is 
sufficient to say that it begins half an inch back of a point midway between the 
glabella and inion. It may be very easily located by Chiene’s method, which con- 
sists in folding a square piece of paper diagonally and folding this again; after 
which it is three-quarters unfolded, the acute angle then representing 672°. If 
this be properly applied to the skull, one edge of its surface can be made to fall 
directly over the Rolandic fissure. The fissure may also be located by a simple 
instrument known as the cyrtometer—a gauged metal strip having a sliding arm 74 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
upon it, which, when the long strip is placed over the longitudinal sinus (i. e. the 
middle line of the skull), can be made to fall directly over the fissure. While 
neither of these methods is invariably and minutely exact, either of them is suffi- 
ciently accurate for all practical purposes. 
The fissure of Sylvius may be indicated by a line drawn from a point 3 cm. 
behind the external angular process to a point 2 cm. below the most prominent 
part of the parietal eminence. The short and ascending limb of this fissure is of 
relatively small importance in this connection. 
Reid’s base-line, so called, is a line drawn from the inferior margin of the orbit 
backward through the centre of the external auditory meatus. It is a line often 
alluded to in cranial topography. The colored plate (see Plate III.) will indicate 
with reliable accuracy the relation of the motor centres to each other and to the 
principal fissures and convolutions. It pertains merely to the left hemisphere of 
the brain, in whose third frontal convolution is placed Broca’s centre for speech, 
the corresponding area upon the right side having no exactly corresponding func- 
tion. The centre for vision, it will be seen, is located in the cuneus, the most 
basal portions of the hemispheres being the seat of the special senses of taste, 
smell, and hearing. 
Operation.—The word trephine is at present used both as a noun and 
as a verb, the older term trepan being now wellnigh discarded. The 
instrument itself, as at present made, consists of a section of a tube, one 
of whose extremities is arranged with sharply-cut saw teeth, the whole 
provided with a grip or handle, which revolves in a plane parallel to 
that in which the saw teeth cut. The best instrument is that arranged 
in a slightly conical manner, so that it may less easily burst through the 
Fig. 18. 
The Powell electric saw cutting a “trap-door” in the skull. 
skull and do harm to parts within. The trephine proper is manipulated 
by the hand. A variety of substitutes have resulted from applications 
of human ingenuity to the problem of opening the cranial bones. Some 
of these are actuated by foot or hand power, with reduplicated mechan- 
isms ; others by electricity. The more complicated the mechanism the 
more likely it is to get out of order, and there are but few of these 
substitutes which give anything like lasting satisfaction (Fig. 18). PLATE 111. 
FIG. i. 
Fissura centralis. 
./Fiss. occipitalis. 
Topographical Anatomy of Cortex. Localization of Functions. (Ziehen.) 
Fig. 2. 
Topographical Anatomy of Inner Surface of Right Hemisphere. Localization of Functions. (Ziehen OPERA TIONS UPON THE CRANIUM. 
75 
In the common parlance of the day the operation of trephining is made to 
include any method by which an opening is made in the uninjured cranium or by 
which an opening already existing is enlarged and made to subserve the surgeon’s 
purpose. Aside from the saws already alluded to, there are in common use a 
variety of cutting bone-forceps, rongeurs of various device, and a variety of 
chisels, which are meant to be used in connection with the mallet or hammer. 
In order to use any of the latter instruments to advantage it is often well, and 
usually essential, to make the first attack with the trephine of reasonable size, 
say 2 to 3 cm. in diameter, after which forceps, chisel, or saw may be used as one 
sees fit. Straight saws are also of occasional usefulness, though not often now 
employed. For my own part, I prefer to use the chisel and mallet relatively 
seldom, feeling that the series of concussions resulting from blows of the hammer 
must add in at least an appreciable degree to the shock of the operation. The 
common trephine is provided with a centre-pin, which can be withdrawn after a 
shallow groove has been cut. To prevent slipping of the centre-pin I prefer to 
mark the point to which it is to be applied by cutting a little nick with the point 
of a chisel. 
In the absence of a wound, relieving one of the necessity of making 
incision, a flap of scalp is deliberately raised before applying the instru- 
ment. When the surgeon has his choice this flap is ordinarily of horse- 
shoe shape, and should be made with its convexity pointing toward the 
Fig. 19. 
Illustrating the use of the common trephine in depressed compound fracture. A horseshoe flap 
of scalp has been turned down, and the trephine is applied to firm, unbroken bone in order to 
make an opening through which the depressed pieces can be attacked and removed. 
occiput, since drainage is best afforded later by this arrangement. The 
old crucial incisions are now wellnigh abandoned. The pericranium 
is detached, after incision, with the periosteum elevator, and it is always 
well to turn it up with its overlying scalp without completely separating 
it. The scalp flap may be best held out of the way by temporarily sew- 
ing it to some other part of the scalp, every portion of which should be 
previously shaved closely and thoroughly scrubbed. The operator has 
his choice—to seize vessels as they bleed or to make the operation in 
large degree bloodless by applying an elastic tourniquet tightly around 76 
INJURIES AND SURGICAL DISEASES OE THE HEAD. 
the scal]> above the eyebrows and beneath the occiput, the ears prevent- 
ing it from sliding. If the tourniquet be used, the vessels will often 
bleed in an annoying way after the wound is closed. If the operation 
be performed for fracture of the skull, should there be an opening 
already made by the depression of fragments it may not be necessary 
to use the trephine at all, but with suitable bone-forceps fragments may 
be removed or detached to the necessary amount. In this case, how- 
ever, there are often sharp points of bone which will require removal 
by cutting bone-forceps, for the surgeon should leave the margin of the 
bone-opening comfortably round and smooth. Should there be no open- 
ing into which the point of an elevator or of a bone-forceps can be in- 
serted, then one must be made; and it is for this purpose that the tre- 
phine is mainly used in cases of fracture of the skull (Fig. 19). It must 
now be applied upon a firm and undetached surface of bone, one which 
will bear the pressure necessary in the process of perforation. As used 
for this purpose, it should be so applied that at least two-thirds of the 
circle cut by its teeth will be upon unbroken skull; the remaining seg- 
ment of the circle may be over the fractured area. After it has begun to 
cut a distinct groove the centre-pin should be withdrawn and the instru- 
ment maintained in its position during its work by a firm and steady hand, 
which shall force it evenly through the bone and not exercise undue 
pressure upon one side or another. As the diploe is perforated the bone- 
dust becomes soft and bloody and the resistance is diminished. As the 
instrument sinks deeper, the operator must frequently intermit its use, 
and determine his position by means of the irrigator and of the probe 
or other instrument. The nearer one comes to the inner surface the 
more caution he must exercise, remembering that the bone is likely to 
be of unequal thickness. When the skull has been completely per- 
forated at one or two points around the little circle the operator should 
introduce the point of an elevator and pry up the disk of bone, or by 
rocking the handle of the trephine he may be able to remove the button 
with that instrument. When the operation is performed in the ideal 
manner the dura is scarcely injured, certainly not sawn through by the 
teeth of the instrument. 
In certain of the exploratory operations upon the skull large tre- 
phines, having a diameter of 7 to 10 cm., are occasionally employed, 
but the force required to actuate these instruments is so great as to 
speedily tire out the hand and arm of any but the most muscular indi- 
vidual. The time consumed is also fully equal to that which would be 
expended in cutting away the same amount of bone with suitable for- 
ceps. 
Before opening the dura every loose particle of bone and every 
splinter should be removed, depressed fragments should be picked out, 
and those which are semi-detached should be raised at least to their 
proper level. Through the opening thus made the dura is carefully 
examined; extradural collections of blood are recognized instantly, 
while some idea as to the amount of intracranial tension may be secured, 
even through a small opening. Nothing abnormal being discovered 
outside of the dura, should brain-tension be great or should the dura 
be discolored, as by blood beneath, the membrane should be opened, 
often again by a triangular or horse-shoe flap, and the subdural condition OPERATIONS UPON THE CRANIUM. 
77 
be accurately estimated. In some cases of meningeal hemorrhage clots 
will be ejected with no little force the instant the dura be opened. In 
other cases of intracranial pressure, either from tumor or from intra- 
ventricular hemorrhage, the brain will instantly protrude to such an 
extent as to make its reposition difficult or even impossible. 
When there is good reason for its use, one need never hesitate to employ a small 
aspirating needle in connection with some good suction apparatus. This may be 
passed to a considerable depth in the brain, when exposed from the vertex of the 
skull, without producing the slightest recognizable disturbance. By its use it is 
often possible to obtain most important information. Cystic accumulations, deep 
hemorrhages, etc. may be determined by this method. 
While the scalp incision may be made practically bloodless by employment of 
the tourniquet, as above mentioned, the blood may continue to ooze from the diploe 
or from the bone, and hemorrhage from this source be a constant annoyance. It 
may be checked by crushing the margin of the opening between the points of blunt 
bone-forceps, by which means the little vessels are compressed; or it may often be 
controlled, as suggested by Horsley, by forcing into the rough margin of bone some 
sterilized wax. 
Incisions in the dura should be made, so far as possible, parallel with its vessels 
rather than across them. When accessible, dural vessels can always he secured and 
tied. Vessels of the pia can also usually be picked up and secured with very fine 
catgut ligatures. The cortex itself is not so vascular as to afford much trouble. 
Upon any portion of the membranes or cerebral surface a sterilized solution of anti- 
pyrine can be sprayed or applied without hesitation (5 per cent, solution). In all 
deliberate operations sinuses are avoided so far as possible. When exposed or when 
necessary to attack them they may be ligated and divided, or may be packed with 
tampons of sterilized iodoform gauze, or may be seized with serrefines or light haemo- 
static forceps, which may be left for a day or two included within the dressings. 
Opening the skull, or, in general terms, trephining, is at present 
resorted to for the following purposes : 
1. For relief of compression: 
a. By depressed bone, as in comminuted or gunshot fracture ; 
b. For removal of clot or ligation of vessels; 
c. For evacution of pus, either from the meningeal cavity or from 
a deeper abscess; 
d. For the removal of serous effusions, either extra- or intra- 
ventricular. 
2. For removal of foreign bodies. 
3. For relief of intracranial irritation—e. g. epilepsy, the psychoses, 
etc. 
4. For removal of tumors. 
5. To compensate for defective development. 
6. For exploratory or purely empirical reasons, including the making 
of “relief openings” for relief of pain, etc. 
Aside from the ordinary methods of trephining as applied for ordi- 
nary conditions, modern surgery comprises the resort to essentially new 
methods for raising areas of skull of considerable size and then restor- 
ing them to their previous position. These are ordinarily spoken of as 
osteoplastic resections, and have added very materially to the art and 
resources of the surgeon. These consist, in a general way, of the forma- 
tion of a window, as it were, in the vertex of the skull by outlining a 
quadrangular or horse-shoe flap of scalp, which is detached only for a 
slight distance around the incision, after which, by use of the revolving 
saw or by chisel and mallet, a groove is cut through the bone running 78 
INJURIES AND SURGICAL DISEASES OF THE HEAD. 
parallel with the margin of the scalp-flap, but perhaps a centimetre 
within it. After this bone area is completely cut through on three sides, 
it is then sprung up or elevated in such a way as to be broken across the 
base of the bone-flap. It is not at all detached nor separated from the 
scalp, and so when subsequently lowered into position retains its vitality 
by virtue of its vascular connections (Fig. 20). 
There is scarcely any reasonable limit to the extent to which this method may be 
resorted to, providing only that the bone be furnished with a sufficient blood-supply 
from undivided scalp. Consequently, the bone peninsula is made on a lower aspect 
whenever a large window is thus to be made. Whether this flap shall be immedi- 
ately secured in position with intimate and primary union, or whether it shall be 
made to cover a gauze packing for a few days, after which it may be restored to 
place, must depend on the purposes of the operation and the completeness of its 
performance in one sitting. 
The practice of replacing buttons of bone removed during trephining has not 
found general favor, and is employed by but few, since in ordinary cases the bone 
defect is replaced in time by fibrous and cicatricial tissue, practically as strong and 
resistant as the original bone. A much easier and equally effective method is to 
Fig. 20. 
“Trap-door” operation: bone-flap turned aside, dura exposed. “Osteoplastic resection.” 
sprinkle over tlie dura when closed some of the fresh bone saw-dust or some little 
fragments of bone, which shall be entangled in the clot and which may Subse- 
quently serve as centres of ossification. 
Where some particular measure seems indicated in order to atone 
for a large defect in bone, it has become quite customary to insert some 
artificial substitute, mainly either celluloid or a thin aluminum plate, pre- 
viously absolutely sterilized and cut at the time into such shape as may 
be called for, but a trifle larger than the real defect, being let in or sprung 
in, as it were, either completely beneath the bone or into the bony open- 
ing, so as not to be easily detached or slip out of the way. By this 
heteroplastic method most admirable results have been achieved. I have 79 
used celluloid for this purpose in the spinal column also, closing with 
it the defect which remained after the extirpation of the sac of a spina 
bifida. 
OPERA TIONS UPON THE CRANIUM. 
The question of drainage will always arise. In a non-traumatic case, where 
every precaution has been observed, drainage will probably only be indicated when 
we are anxious to provide for the escape of blood or of cedeinatous elfusion. In these 
instances it can be made with gauze, strands of catgut, or some other capillary 
drain. In cases of injury to the head much will depend upon the nature of the 
case and the time which has elapsed between injury and operation. Should time 
for infection have been given, with probability of its occurrence, it is much better 
to insert an antiseptic packing, and to close the scalp, if at all, by secondary 
sutures. In other instances it may be enough to insert a capillary drain or to leave 
out two or three sutures from the lowest portion of the incision, providing in this 
way for the escape of material. Halfway measures, however, are most ill advised; 
and if one be in doubt, it is much better to leave the wound widely open than to 
close it in such a way as to in the slightest degree contribute toward retention of 
that which should escape. In brain-abscesses, etc. a rubber drainage-tube or cap- 
illary drain wrapped up in green-silk protective will certainly be required. 
External dressings should be both profuse and absorbent, and are best held in 
place by starched bandages. Absolute physiological rest should be insisted upon 
in the after-treatment, and the excretions should be kept lively, in accordance with 
the principles enunciated in the earlier portion of Volume I., in order that auto- 
intoxication in any form may be carefully guarded against. CHAPTER II. 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
E. H. Bradford, M. D. 
Spina Bifida. 
Spina bifida is a congenital deformity of the spinal column due to a 
lack of development of certain of its bony factors. As a result, the 
laminae of one or more vertebrae do not unite at the spinous processes 
and a space is left uncovered by bone. The gap may rarely involve the 
bodies of the vertebrae, but much more commonly is limited to the pos- 
terior portion only. As a result, 
the lesion is either in or very close 
to the median line. Through this 
opening the contents of the spinal 
canal may, and usually do, project, 
causing a tumor of variable size, 
Fig. 22. 
Fig. 21. 
Dissected sac in spina bifida (Warren Museum). 
which may be sessile or may be narrow at the neck, with a true pedicle. 
Of all the cases, 50 per cent, occur in the lumbar region, 12 percent, in 
the lumbo-sacral, and 7 per cent, in the sacral. Spina bifida is, then, the 
most common in the lumbar and lumbo-sacral regions, more rare in the 
cervical, almost unknown in the dorsal. The contents of the tumor 
Vertebra in spina bifida (Warren Museum). 
80 SPINA BIFIDA. 
81 
may be the cerebro-spinal fluid, the cord itself, or, in the region of the 
cauda equina, the spinal nerves and nerve-filaments. If the sac con- 
tains the lining membranes of the cord and cerebro-spinal fluid, the 
tumor is called a meningocele; if besides the fluid the tumor contains 
the cord, it is termed a meningo-myelocele ; if the cord within the 
tumor is dilated with fluid, it is described as a syringo-myelocele. 
The second of these forms is the most common. The skin covering the 
tumor may be normal, but is more usually either thickened or thin or 
translucent. In some instances the skin is absent. 
There is usually a direct communication with the fourth ventricle through the 
pia mater at the lower border of the fourth ventricle. This communication, how- 
ever, may be obstructed, and in some instances there may be no communication 
between the sac and the spinal canal. The cord may be situated behind the sac, 
or it may be spread out on its internal surface, or it may lie in front of the sac. 
Pressure upon the tumor usually evacuates its fluid contents slowly, but only by 
increasing the amount of the cerebro-spinal fluid in the spinal and cranial cavity, 
often with symptoms of intracranial pressure. 
The amount or character of the contents can- 
not be positively inferred from the size of the 
tumor, nor does a large tumor necessarily 
presuppose a large loss of bony substance in 
the column. Sometimes the tumor may be so 
small as to be unnoticed. 
These cases seldom cause noticeable 
symptoms; exceptionally the reverse is 
true, and serious pressure-symptoms 
appear where the exciting cause is found 
to be bands of connective tissue at the 
level of the spinal opening, exerting 
compression upon the cord. This vari- 
ety is called spina bifida oeculta, and is 
often characterized by a patch of hair 
externally. The size of the tumor varies 
from that of a cherry to that of a cocoa- 
nut. If the tumor be of considerable 
size and the cuticle be at all thin, it may 
increase in size upon physical exertion, 
such as coughing, vomiting, sneezing, 
crying. The rapidity with which the 
tumor may be emptied under pressure 
indicates roughly the size of the open- 
ing in the spinal canal. 
The diagnosis usually offers no 
difficulty. If a child present a rounded 
congenital tumor in the lumbar, lumbo- 
sacral, sacral, or cervical region, in the 
median line, often varying in size, either 
with or without a pedicle, and with 
fluctuating contents, it certainly may be regarded as a spina bifida. 
The course of spina bifida varies. In the majority of instances the 
tumor ruptures during infancy, the fluid is evacuated, and the patient 
dies with convulsions or from a septic spinal meningitis. In some 
instances, however, a spontaneous recovery takes place, and in rare cases 
Fio. 23. 
Spina bifida in infant. 82 
INJURIES AND SURGICAL DISEASES OF T1IE SEINE. 
the gap in the bone is closed by a subsequent bony growth. Such spon- 
taneous closure may be observed in a certain number of instances even 
where it is evident, from paralysis of the lower extremities, that portions 
of the cord are involved. In another class of cases the life of the child 
is not directly threatened, but serious symptoms are developed, due to 
the involvement of cord or nerves. In still another class of cases the 
condition continues indefinitely without serious symptoms. 
Treatment.—Treatment may be either conservative or operative. 
Conservative treatment consists of protection of the sac from violence 
and an effort to prevent the increase of the tumor in size. The tumor 
should be covered with absorbent cotton and a shield placed over 
it. The shield may be made of brass, silver, or aluminum, hammered 
over a plaster cast of the tumor. It may be held in position by a band 
Fig. 24. 
case of spina bifida. 
which encircles the child’s body or by adhesive plaster. Attempts to 
diminish the size of the tumor by pressure are manifestly irrational, and 
have been known to result fatally by developing a hydrocephalus, rup- 
turing at the anterior fontanelle. If the skin over the tumor become 
thin, a layer of cotton is to be placed upon the thinnest portion of the 
skin and held in place by collodion. 
Of operative measures, two only are worthy of attention: The first, 
the injection of an irritant within the sac ; the second, excision of the sac. 
Various methods of injection have been employed, but the following 
is most to be recommended : The sac is punctured on the side, the trocar 
being passed obliquely through the healthy skin, and a certain amount 
of the fluid is drawn off. If the sac is not large, it is better at the first 
tapping only to draw off a small amount of fluid. From one to two 
drachms of a solution of iodo-glycerin should then be injected sub- SPINA BIFIDA. 
83 
cutaneously (1 part iodine, 6 parts potassium iodide, and 50 parts glv- 
cerin). A moderately fine trocar should be used. After the injection 
the opening should be closed with dry gauze secured by collodion and 
iodoform. The surface of the tumor should be rendered scrupulously 
clean before the puncture is made. The operation may be repeated from 
four to six times at intervals of a week or ten days. 
This method has been especially advocated by Morton of Glasgow: its value 
was investigated by the London Clinical Society, which collected 82 cases (treated 
by Morton’s method); of these, 35 recovered and 37 died. In 5 there was no 
improvement, and in 4 there was slight improvement. Morton himself reports 67 
cases, with 55 recoveries and 10 deaths. Powers has collected 15 cases, with 4 
deaths. 
Excision of the Sac.—The treatment of spina bifida by excision of the 
sac has been successfully done in a number of instances. Various methods 
of operation have been advocated. An obstacle to a successful operation 
is met in the difficulty in preventing the copious escape of cerebro- 
spinal fluid, which by moistening the aseptic dressings becomes a source 
of infection. The simplest method of operation consists in dissecting 
lateral skin-flaps, opening the sac, returning into the spinal canal any 
nerve-structures that can be found, closing the divided and dissected 
emptied sac by means of careful suturing, and uniting the skin-flaps 
over the whole. Where the opening is large it is not desirable to sac- 
rifice much of the sac, but to fold it into the canal, stitching the opposing 
external surfaces. If the opening be small, the redundant sac-flaps 
should be cut off and the cut edges carefully sutured. The treatment of 
the skin-flaps must necessarily vary according to the size of the opening 
and the amount of skin. 
Osteoplastic methods have been used in the attempt to close the opening by 
dividing the arches of the vertebra and forcing them together near the median 
line, securing them by suture. Where the opening is small and the tumor is 
pedunculated, the sac which contains the dura can be ligated and covered by skin- 
flap. Attempts have been made to promote the growth of bone by means of trans- 
planted periosteum and by aseptic bone spiculse. Park of Buffalo has successfully 
closed the opening by the insertion of a celluloid plate. Hanson has collected 
150 cases of spina bifida treated by excision since the introduction of antiseptic 
surgery: 25 of these were under the care of Swedish surgeons. The mortality 
from the operation in the whole number was 29 per cent. 
Robson thinks excision under aseptic surgery exposes the nerves in the sac to 
less irritation than the injection of an irritating' fluid. He has collected 20 cases 
of excision of the sac—4 cervical, 16 lumbo-sacral and lumbar. There were 5 
deaths—1 on the table, 1 in thirty-six hours, 3 in from three to fourteen days. Of 
these cases he considers that in 1 the operation was not necessary, and in 2 was not 
advisable. 
There are manifestly three classes of spina bifida : 
1. The slight cases, not threatening to burst or enlarge or seriously 
incommode the patient. 
2. The cases beyond surgical reach, where operation is not indicated 
owing to the condition of the child and the size of the tumor. 
3. In those cases where the deformity threatens either life, long 
disability, or death in time, operative measures are to be seriously con- 
sidered. 
It would seem that in the cases needing operative interference excis- 
ion is more thorough and surgical than puncture and injection of 
iodine, providing asepsis can be secured. 84 
INJURIES AND SURGICAL DISEASES OE THE SEINE. 
It should be borne in mind that the percentage of spontaneous cure 
has not been accurately determined, and that cases have been observed 
where spontaneous recovery has taken place after spontaneous rupture 
of the sac with subsequent gradual narrowing and, in some instances, 
closing of the bony opening. 
Sacral Cysts. 
Tumors occasionally present themselves in the sacrum, with the cha- 
racteristics of fatty tumors, lying under the fatty tissue in the region of 
the buttock. These tumors are usually in the median line, but in some 
Fig. 25. 
Sacral cyst, showing defect in sacrum (Warren Museum) 
instances may lie somewhat to one side. The size of the tumor varies, 
and in some instances there may be fluctuation, though this is not always 
the case. 
If an incision be made, these tumors will be found to be filled with cerebro- 
spinal fluid, and if explored an opening will usually be discovered communicating, 
through another in the sacrum, with the spinal canal. These tumors are, in fact’ 
similar in nature to spina bifida occulta. Operative interference in these cases is 
a more'dangerous procedure than would be imagined, for the reason that it is diffi- 
cult to secure complete asepsis, owing to the leaking of the cerebro-spinal fluid 
after operation and the difficulty of securing a proper dressing in that portion of 
the body in a young child. 
Syringomyelia. 
This term is applied to an irregular enlargement of the central canal 
of the spinal cord, which, beginning as a congenital defect, is increased 
in later life, with corresponding disturbance in nerve-function, the most 
noticeable being a blunting of the sensibility to heat and cold, combined 
with impairment of the motor and tactile sense. The cavity, which 
may contain fluid, is sometimes so extensive as to encroach on the normal 
cord-structure, and give rise to loss of integrity of the parts affected by 
this pressure, with great disturbance in the" patient’s condition and 
activity. The affection is one which rarely comes to the attention of 
the surgeon. Keen mentions 2 cases of his own and 1 of Abbe operated COCCYGEAL DIMPLE AND SINUS.—FRACTURES. 
85 
upon by laminectomy : there was, however, no benefit, and the operation 
is of doubtful value. 
Coccygeal Dimple and Sinus. 
A small, shallow depression or dimple of the skin is not infrequently 
seen in the region of the coccyx. This is a vestige of the foetal opening 
of the spinal canal. 
The closure has been completed in these instances to such an extent 
that for all practical purposes the opening is entirely covered in, there 
remaining only a depression in the skin from the incomplete deposit of 
fat, similar to what is observed over a healed sinus or over the umbili- 
cus. There is in a coccygeal dimple, however, no evidence of scar or 
break in the skin. 
The depression when present varies in different individuals from a 
scarcely perceptible trace to a cul-de-sac of considerable depth, which 
may become the seat of inflammation. When the depression is suffi- 
ciently deep to form a sac, it may collect sebaceous matter, desquamated 
epithelium, or foreign substances, dust, cotton or woollen fibre, which, 
acting as irritants, excite inflammation. If the resulting suppuration 
do not find free vent, it undermines the skin and an abscess of con- 
siderable size may be developed. In certain instances the cavity con- 
tains a fold of hair growing from the normal skin which forms the wall 
of the sac. 
There is usually an opening from such a cavity, the coccygeal depres- 
sion forming a sinus which has been termed a pilo-nidal sinus, as it 
appears like a nest for the growth of a tuft of hair. Hair, however, is 
not invariably present. The affection often presents itself as a sinus of 
considerable size, with ragged granulating edges, in the centre of a mass 
of brawny skin and situated in the median line or the base of the coccyx. 
The sinus can be traced through the subcutaneous tissue to the peri- 
osteum covering the sacrum and coccyx and into a cavity of undermined 
tissue. 
The treatment is simple. The cavity is to be laid open freely, the 
inflammatory tissue forming the lining wall is to be thoroughly curetted, 
and a packing of iodoform gauze inserted to promote healing from the 
bottom of the cavity. 
INJURIES OF THE SPINE 
The injuries to the spine consist of— 
1. Fractures; 
2. Dislocations; 
3. Fracture and dislocation combined; 
4. A strain of the spine, with rupture of or injury to the mus- 
cles and ligaments; 
5. Injuries to the cord and spinal column. 
Fractures. 
Fractures result either from direct violence, a blow from a height upon 
the spi ne, a fall, striking upon an irregular hard surface or projection, 86 
INJURIES AND SURGICAL DISEASES OF TIIE SPINE. 
or from the violent bending or twisting of the spine. As considerable vio- 
lence is required to produce a fracture of the spine, the lesion is often 
accompanied by some displacement. If this be considerable, it amounts 
to a combination of fracture and dislocation. There is frequently also 
hemorrhage within the canal, and in many instances bruising or crushing 
of the cord by the displaced fragments. 
Fractures of the spine are not common, forming but 3-4 percent, of 
all fractures. They are more common in the dorsal and cervical region 
than in the lumbar, where the vertebrae are stronger. 
Fractures are more frequent in adult males than in 
women and children, as the former are more exposed 
to violence than the latter. 
The recognition of fracture of the spine is ordi- 
narily not difficult. The resulting disability is neces- 
sarily great, and the evidence of a local injury is 
manifest as a rule. There is frequently also proof of 
injury to the cord from paralysis of the bladder and 
rectum or of the limbs. 
In some instances, however, where there is but 
little displacement and the injury is in the anterior 
portion of the column, the lesion is only recognized 
by the injury to the nerves or cord, and is mani- 
fested by paralysis of motion or of sensation and the 
condition of the reflexes. 
As Keen has well expressed it, “ The spinal cord 
may be considered as made up of a series of hori- 
zontal segments, placed one on top of another like a 
pile of checkers, and one pair of nerves, right and 
left, arises from each segment. For example, the 
fifth cervical segment would be that segment of the 
spinal cord from which the fifth cervical nerve-roots 
take their origin.” These segments do not agree in 
position with the numerically corresponding verte- 
brae. Thorburn has called attention to the fifth-root 
group of muscles and the position assumed by the 
patient who has had the fifth cervical nerve crushed. 
Where this is injured the patient will lie with his 
arm in a peculiar attitude; or, in other words, if the 
fracture be below the fifth cervical nerve there will be 
abduction and flexion at the elbow, the hand will be 
supinated, and the humerus externally rotated. If 
the fifth cervical nerve be involved, the deltoid muscle 
is paralyzed and the elbow will lie next the body. 
At other levels the position will not be so character- 
istic. The area of anaesthesia, also varies according to the level of the 
injury. In general, it may be said that the outer parts of the upper 
extremities correspond to the upper nerve-roots, the inner portions to 
the lower. Starr concludes that in the spinal cord the centres of control 
of the bladder and rectum are always affected together. Control over these 
sphincters is lost when the lower three sacral segments are involved. The 
condition of the reflexes will indicate an injury to the cord at certain 
Fig. 26. 
Fracture of body of 
vertebra (Warren 
Museum). FRACTURES. 
87 
points, and it is possible with careful examination to determine whether 
there is a total or partial transverse lesion of the cord. Complete tram- 
verse destructive lesions of the cord will give complete muscular paralysis 
of the parts below the level of the injury, complete ancesthesia below the 
level of the injured nerve, and there- 
fore complete abolition of the knee- 
jerk and deep reflexes; but if the 
Fig. 28. 
Fig. 27. 
Crushing fracture of vertebral body (Park). 
Fracture of spine with displacement: section 
of vertebrae (Warren Museum). 
fransvet'se lesions of the cord are partial, the muscular paralysis and 
anaesthesia will be incomplete. The visceral reflexes, especially those of 
the bladder and rectum, are affected in the same way. 
Differential Diagnosis of Diseases and Injuries of the Spine and Spinal 
Cord. 
Fracture. 
Dislocation. 
Hsematomyelia. 
Hxmatorrhacliis. 
Acute 
Poliomyelitis. 
Onset. 
Immediate. 
Immediate. 
Immediate. 
Progressive. 
Slow. 
Anaesthesia. 
“ 
“ 
“ 
Incomplete. 
Absent. 
Paralysis 
(is of hemiplegic 
type when com- 
pression is unilat- 
e r a 1, paraplegic 
when bilateral, 
and local when 
n e r v e-roots are 
involved). 
Hemi- or 
para ple- 
gia. 
Hemiplegia. 
In partial 
d isloca- 
tion may 
be absent. 
Paraplegia. 
Hemi- or para- 
plegia. 
Paraplegia. 
Deformity. 
Usually 
present. 
Present. 
Absent. 
Absent. 
Absent. 
Temperature. 
Rises after 
second or 
third day. 
Same. 
Same. 
Same. 
Precedes the 
paralysis of 
degenera- 
tion. 
Bowels and bladder. 
Paralyzed. 
Paralysis 
usual. 
Same. 
Affected late 
if at all. 
No paralysis. 88 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
In the diagnosis of injuries to the spine and its contents it should be 
remembered that sudden paralysis may be caused by— 
1. Hemorrhage- 
haem atomy el i a, 
haematorrhachis. 
2. Embolism. 
3. Fracture. 
4. Dislocation. 
Rapid paralysis may be caused by— 
1. Hyperceniic exudate in process of repair. 
2. Inflammatory exudate. 
3. Pus. 
4. Hemorrhage. 
5. Acute poliomyelitis. 
The subjoined table, inserted by the kindness of Dr. Dennis, will 
assist in locating the lesion : 
Paralyses and Reflexes due to Spinal Injury. 
Spinal 
Nerve. 
Motor Paralysis. 
Anaesthesia. 
Reflexes. 
r i. 
Death from pressure of 
odontoid. 
2-3. 
Death from paralysis 
of diaphragm. 
4. 
Deltoid muscles of up- 
Upper shoulder, outer 
Pupil. 
per arm. 
arm. 
15 
5. 
Supinators of hand. 
Outside of arm and 
Pupil, scapular, supina- 
*> - 
forearm. 
tor, triceps. 
0) 
O 
6. 
Biceps, triceps, exten- 
Outer half of hand. 
Pupil, scapular, triceps, 
sors of wrist. 
post, wrist. 
7. 
Pronators of wrist, la- 
Inner side of arm and 
Pupil, scapular, post. 
tissimus dorsi. 
forearm. 
wrist, ant. wrist, pal- 
mar. 
8. 
Flexors of wrist, hand, 
Inner side of hand. 
Scapular, post, wrist, 
muscles. 
ant. wrist, palmar. 
1- 
Thumb. 
Ulnar supply to hand. 
Scapular, palmar. 
2-12. 
Muscles to back and 
Skin over back and 
Epigastric, 4-7 ; abdom- 
13 
Cfi 
J- - 
O 
abdomen. 
abdomen in areas 
corresponding to 
inal, 7-11. 
Q 
- 
distribution of spi- 
nal nerves. 
1. 
Psoas and sartorius. 
Groin. 
Cremasteric. 
2. 
Quadriceps ext. femo- 
Outside of thigh. 
Cremasteric, patellar. 
in 
3. 
Abductors and inner 
Front and inside of 
Cremasteric. 
rotators of thigh. 
thigh. 
s 
13 
4. 
Adductors of thigh, 
Inside of leg, ankle, 
Gluteal. 
tibialis anticus. 
and foot. 
5. 
Outward rotators of 
Back of thigh and leg; 
Gluteal. 
. 
thigh, flexors of knee 
and ankle. 
outside of foot. 
13 
fl-2. 
Muscles of foot, pero- 
Outside of leg. 
Plantar. 
s 
c3 
3-5. 
1161. 
Perineal muscles. 
Perineum, anus, sac- 
Ankle-clonus. 
02 
1 
rum, genitals. 
The bladder and rectal centres are in the lower lumbar segments, 
and traumatism in this region causes incontinence of urine and faeces. 
Injuries higher up cause retention. FRACTURES. 
89 
Reflexes are elicited as follows : 
Pupillary : Dilatation produced by pinching side of neck. 
Scapular : Scratching skin over scapula causes muscles to contract. 
Supinator : Tapping tendon at wrist causes flexion of arm. 
Triceps : Tapping tendon at elbow causes extension of arm. 
Posterior wrist: Tapping tendons causes extension of hand. 
Anterior wrist: Tapping tendons causes flexion of wrist. 
Palmar : Scratching palm causes flexion of fingers. 
Epigastric : Stroking mammae causes retraction of epigastrium. 
Abdominal: Stroking abdomen causes retraction. 
Cremasteric : Stroking inner thigh causes retraction of scrotum. 
Patellar : Striking patellar tendon causes extension of leg. 
Gluteal: Stroking buttock causes dimpling in gluteal fold. 
Plantar : Stroking sole of foot causes flexion and retraction of leg. 
Ankle-clonus: Forcible extension causes rhythmical flexion.1 
The prognosis of fracture of the spine is very grave. Gurlt 
reports 217 deaths in 270 fractures, but statistics are not of absolute 
value unless they are still further 
classified according to the nature of 
the accident and site of the fracture. 
Treatment.—The treatment is 
either non-operative or operative. 
Operative treatment consists of 
laminectomy for the purpose of re- 
moving from the cord the pressure 
of extravasated blood or loose spic- 
ulae of bone. 
Chipault advocates early interference 
if an operation is to be done, owing to the 
fact that degenerative alterations of the 
cord take place within twenty-four hours, 
as has been shown by experiments on ani- 
mals and autopsies. Lauenstein believes 
that even if there is incontinence of urine 
and faeces, with cystitis and bed-sores, an 
operation is justifiable, as recovery cannot 
be expected without operation. Horsley 
is definitely in favor of an operation in all 
cases where there are symptoms which 
would show pressure upon the cord. Bur- 
rell analyzed 168 cases, and advocates ope- 
ration in the first twenty-four hours in all 
cases of fracture, even including those in 
the cervical region. Thorburn has reported 
61 cases of operation, with 35 deaths; 
Chipault has collected 95 cases, with 38 
deaths; Lloyd has found mortality of 57 
per cent, after operation. 
The danger from an operation in- 
creases with the height of the lesion. 
Where the fracture is limited to the 
arches, with displacement, an operation is manifestly indicated. Chipault 
concluded that in cases of lumbar or sacral fractures surgical interference 
Fig. 29. 
Specimen of consolidated fracture of the 
spine (Warren Museum). 
1 From Dennis, by permission. 90 
INJURIES AND SURGICAL DISEASES OE THE SPINE. 
should be undertaken at once if there be prominence—i. e. deformity. 
If there be a permanent and irreducible displacement of the bony frag- 
ments, and the fracture can be reduced by manipulation or is reduced 
spontaneously, operation should be delayed, but if the case remains 
stationary, interference is justified toward the end of the first month, 
but not later. 
An operation is not indicated if it is certain that the cord is de- 
stroyed. Where it is uncertain, as is usually the case, and where there 
are symptoms of constant pressure upon the cord from hemorrhage, 
laminectomy is to be advocated. The procedure, however, is one which 
in itself involves considerable danger, and should not be undertaken if 
it be clear that the patient is unable to endure the shock of the operation : 
this, however, is a question which can only be determined on examina- 
tion of each case. 
A description of the operation of laminectomy is given later. 
Non-operative treatment of fracture of the spine consists in placing 
the trunk and spinal column in such a position as will promote healing. 
This can be done in an ordinary fracture bed, steadying the patient by 
sand-bags if necessary. The fixation of the patient’s trunk in plaster- 
of-Paris bandage is of assistance "where it is possible. Some surgeons 
have recommended the suspension of the patient, with or without an 
anaesthetic ; the procedure is, however, not without danger. The method 
of application of the plaster corset upon the patient lying in a sheeting 
hammock, such as is used in caries of the spine, as described elsewrhere, 
has much to recommend it. No anaesthetic is required, and a convenient 
method for an attempt at rectification of the malposition following injury 
is afforded. 
It should be borne in mind that it is essential that the spine be placed in 
such a position that the fragments are as nearly as possible in normal relation. 
Sagging of the bed is to be prevented, and it is sometimes necessary to arch the spine 
forward (as in Pott’s disease) by the use of pads. Traction is sometimes advisable, 
especially in the cervical region. It may be said that the fixation and placing of 
the patient are not unlike that necessary in Pott’s disease. Especial care is neces- 
sary to guard the patient from bed-sores. 
Dislocation op the Spine. 
Ashhurst has collected 394 cases of severe injuries to the spine, of 
which 124 were pure dislocations, the remainder being dislocations with 
fractures. It is difficult, however, if not impossible in many instances, 
to make a certain diagnosis between the two injuries. As a rule, the 
dislocation is bilateral; in some instances it is unilateral. Unilateral 
dislocation of the spine in the cervical region produces a twist of the neck 
resembling torticollis. The face is turned to the opposite side, and 
abnormality in the line and position of the spinous and transverse pro- 
cesses with muscular rigidity is present. If the dislocation be higher, 
there will be dyspnoea. In some of these instances the torticollis from 
high cervical caries following an injury is regarded as an old dislocation. 
The appearance and symptoms are somewhat the same, and there is 
a noticeable twist, with an alteration in the position of the transverse 
and spinous processes. A diagnosis can, however, be made by a careful 
investigation of the history of the case, as the torticollis from disloca- DISLOCATION OF THE SPINE. 
91 
tion appears immediately after the injury, while that from caries is 
developed more gradually. In bilateral dislocation the head is thrown 
back, the chin raised. 
Dislocation of the Occipital Bone from the Atlas.—Stimson 
claims that there are three undoubted cases of this extremely rare acci- 
dent, which is almost invariably fatal. Extraordinary violence is 
required to produce this lesion, as this articulation is very strongly pro- 
tected by ligaments and muscles. 
Dislocation of the atlas from the axis is not so uncommon. It 
is, however, always fatal. The chin is found flexed upon the chest. 
Death is almost immediate, and comes from the injury to the respira- 
tory centres. 
In dislocation of the lower five cervical vertebrae the patient’s 
face is usually drawn away from the side of dislocation. There is a 
prominence on the dislocated side, the muscles being put upon the stretch 
Fig. 30. 
Fracture dislocation with great displacement—patient almost completely recovered (Park) 
upon that side; those upon the opposite side are relaxed. There is 
deviation of the spinous processes. There is frequently deformity inside 
the pharynx. Dislocation without fracture in the dorsal and lumbar 
region is extremely rare. 
Forcible reduction of dislocation of the spine is necessarily a pro- 
cedure of gravity. In the cervical region it has been done with success. 
Great care is needed in the administration of the anaesthetic. An assist- 
ant steadies the trunk, while the surgeon, standing at the head of the 
operating table, holds the patient’s head (in cervical dislocation) firmly 
between his hands, the fingers grasping the back of the neck, the palm 
pressing upon the lower jaw, and with the thumb reaching under 
the chin : the necessary amount of traction and manipulation is thus 
possible. After the correction of the deformity the patient should 
be placed upon a bed-frame and the head steadied by means of sand- 
bags. 92 
INJURIES AND SURGICAL DISEASES OE THE SPINE. 
Wounds of the Spine. 
The penetrating- wounds of the spine result either from violence, 
the use of knives or missiles in war, or from accidents, splinters with 
penetration of wood, cutting instruments, or falling. They either injure 
the bone alone or, entering the canal, divide the cord partially or com- 
pletely. The larger vessels near the column may be injured, causing death 
by hemorrhage. If the bone alone be injured, the case involves no 
great danger. The wound should be thoroughly cleansed and recovery 
can be expected. Where a large artery is divided an exploratory incis- 
ion is necessary, with control of the hemorrhage by haemostatic forceps. 
In some instances it is impossible to reach the bleeding bone, when 
pressure by means of packing with antiseptic gauze is all that can be 
done. In the neck, where the vertebral artery lies close to the column, 
hemorrhage is to be especially dreaded. 
When the wound of the back involves injury to the spinal cord, the 
symptoms are much more alarming. In some instances, though they 
are exceptional, the membrane alone is injured. Ordinarily, the cord is 
either crushed, divided completely across, or partially incised. Cases 
of injury of the entire cord above the fifth cervical segment are neces- 
sarily promptly fatal. 
Other cases are recorded of partial incision of the cord which have 
been followed by almost complete recovery. Where there is injury to 
the cord there is necessarily paralysis, either complete or partial accord- 
ing to the extent of the injury. It should be remembered that if the 
division of the cord be unilateral, the paralysis is a cross-paralysis, as 
has been pointed out by Brown-Sequard and confirmed bv 78 carefully 
recorded cases. The paralysis of motion is on the side of the injury, 
while on the opposite side there is impairment or loss of sensation. 
The treatment of this injury should be governed by ordinary sur- 
gical indications, such as cleanliness and drainage. Where vessels are 
injured the hemorrhage should be checked. In some instances it may 
be necessary to explore the wounds to see if any foreign body remain in 
the canal. Thorburn has collected 34 cases, with 21 recoveries—3 com- 
plete, 16 with a persistence of some motor or sensory impairment. 
Gunshot Wounds of the Spine.—These injuries may vary from the 
perforation of small portions of the spinal column to the most extensive 
destruction. The nature of the wound depends somewhat upon the size 
and range of the missile. There is always considerable shock following 
the injury, and the lesion is necessarily grave. The lower in the column 
the wound, the less the mortality; in the cervical region the mortality, 
according to the Medical and Surgical History of the Civil liar, is 70 
per cent.—63 per cent, in the dorsal and 45 per cent, in the lumbar 
region. 
The symptoms vary with the extent of the injury and the part 
injured. Where the missile gives rise to contusion of the spine, there 
is a temporary disturbance of the function of the cord. Wounds of the 
muscles or injuries to the ligaments give rise to stiffness of the back. In 
some instances suppuration and necrosis follow. Where the spinal canal 
is opened there may be escape of cerebro-spinal fluid, though this symp- 
tom is not constant. Where the cord is injured there is partial or 93 
SPASM OF THE SPINAL COLUMN. 
complete paralysis, with resulting anaesthesia and hyperaesthesia. The 
transverse and spinous processes are more frequently injured than the 
bodies, but when the latter are wounded the lesion is necessarily more 
grave. 
The treatment consists in cleansing the wound, establishing drain- 
age, and removal of foreign substances and of such spiculae as can be 
easily reached. A thorough exploration, with removal of the spinous 
process, or a laminectomy for the relief of pressure by hemorrhage, 
would be indicated under certain circumstances where there is a his- 
tory of paralysis following the injury after an interval of freedom from 
paralysis. 
Park has operated on one case of gunshot wound of the spine and cord, the 
ball entering the chest, passing through the lung, and lodging in the vertebral 
column, where, after opening the spinal canal, air entered the chest through the 
bullet-track, the patient thus breathing partially through his back. 
Spasm op the Spinal Column. 
The spinal column is firmly held by strong ligaments and protected 
by muscles: it is not, therefore, as liable to receive the slighter injuries 
as the less protected articulations. In severer injuries, however, it may 
sustain the same lesions as other articulations, and a sprain of the spine 
will give rise to distressing symptoms analogous to the sprain of the 
large joints. Even when there is no injury to the bony structure or to 
the cord patients will suiter pain, distress on motion, and disability from 
the rupture of the ligamentous fibres connected with the spinal support. 
Many of these cases, combined with the nervous disorganization accom- 
panying invalidism and following an injury, present functional symp- 
toms not dissimilar to those seen in the traumatic neuroses. Patients 
of this class need careful treatment. 
Sufficient amount of rest should be enforced to permit healing of torn 
ligamentous fibres, followed by such measures as will improve the circu- 
lation and diminish the congestion and local swelling following sprains. 
Massage, electricity, and gymnastic exercises (carefully graded) will 
gradually effect a cure. 
Contusions and sprains of the trunk following railway accidents pre- 
sent certain features. From the medico-legal complications to which 
railroad injuries often give rise, the symptoms vary greatly according to 
the condition of the patient, and are often complicated with studied 
exaggeration and malingering. 
The symptoms are at first those of a contusion or sprain, followed by 
those which result from the confinement after an injury, and resembling 
those seen in neurasthenia and general invalidism. These are recognized 
by their varied and ill-defined character, unlike those of a true organic 
lesion. It is often necessary that the injury should be treated at first as 
if a severe contusion were present: after the lapse of sufficient time for 
recovery from any traumatism, if symptoms still are present, they should 
be treated as neurasthenic cases are treated, by muscular development 
and stimulants to the circulation, muscle-building, and nerve-training. 
These cases are not to be confounded with those of true malingerers, 
where recovery takes place immediately after the verdict. 94 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
Concussion and Contusion of the Spinal Cord. 
The existence of contusion of the spinal cord has been questioned, 
but there is apparently no doubt that a severe lesion may take place in 
the cord without any external evidence of injury. 
Gull has reported a case where death followed within fifty-five hours after an 
accident, with no external evidence of injury. At the •post-mortem examination 
some small extravasations of blood into the anterior and posterior cornua and in 
the posterior columns were found. There had been complete paralysis in the 
upper and lower extremities. Hulke has reported a case where there was an 
imperfect recovery from paralysis, and Bastian has reported a case where death 
occurred six months after the accident, a fall of twenty-five feet. There was no 
evidence of fracture or compression upon the cord nor injury to the structure of 
the cord, but there were microscopic lesions in the substance of the cord, with 
secondary degeneration and atrophy of the sympathetic ganglia. These lesions 
had developed without external mark of violence. After the accident there was 
complete paralysis of motion in the leg and paralysis of the right arm. The 
patient had recovered somewhat after the injury, but contractions had persisted. 
The importance of these few cases lies in the fact that they appear to support the 
theory that although the spinal cord is carefully protected in the canal, both by 
the solidity of-the.structures which surround it and by the strength of the attach- 
ments which support it, yet in some instances of comparatively slight violence 
without external injury, lesions in its structure may take place. It is difficult to 
explain, the physical laV by which such injuries are inflicted, but the facts cited 
seem, beyond question. •; 
Spinal Hemorrhage. 
Hemorrhage may take place in the cord or within its membranes— 
i. e. they may be extradural or subdural. It may also occur in the 
structure of the cord itself, a lesion termed heematomyelia. Gowers 
claims that this is a rare lesion, whereas Thorburn considers it not infre- 
quent, and in examining 21 cases of injury to the spine found it in 6. 
It is more common in the cervical region. Where the hemorrhage is 
sufficient in extent to destroy the tissues paralysis and atrophic changes 
result. If, however, the lesion simply give rise to compression, the 
symptoms subside as the blood absorbs, leaving spastic symptoms in the 
lower limbs if degenerative changes have taken place. The attack is 
sudden, a distinct interval of time usually elapsing after injury, with 
paralysis and anaesthesia below the point of lesion and retention of 
urine and faeces. Where the hemorrhage is in connection with the 
membranes the lesions is termed hcematorrhachis. It may be under the 
arachnoid, within the dura, or outside of the dura. ( Vide Plate I V.) 
Laminectomy has been performed for spinal hemorrhage, and, 
although the results up to the present time are not encouraging, yet the 
procedure is indicated in every instance where the patient’s condition 
warrants any surgical intervention. 
Pott’s Disease ; Spondylitis ; Vertebral Caries. 
Pott’s disease, or caries of vertebral bodies, was first described 
by Percival Pott in 1779. It consists of a destructive ostitis affecting the 
spongy tissue of one or more of the bodies of the vertebrae. The 
ostitis is tuberculous, and is similar in character to tubercular ostitis 
seen in the epiphyses of the long bones. The changes in tubercular PLATE IV. 
Intraspinal Hemorrhage, mostly Subdural, with Minute 
Subpial Ecchymoses. (Park.) POTTS DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
95 
ostitis are described elsewhere in this work (Volume I. Chapter 
XXXV.). 
Owing to the superincumbent weight of the head and shoulders 
pressing upon the carious vertebral bodies, the spine and trunk become 
peculiarly and characteristically distorted. The morbid process is 
limited, as a rule, to the bodies; the transverse, articular, and spinous 
processes are rarely primarily affected. 
Tubercular ostitis of a vertebral arch has been reported by Roberts of Phila- 
delphia. Primary disease of the intervertebral cartilage must also be extremely 
rare, if it exist at all. Various portions of the vertebral bodies may be affected. 
There may be two or more foci in one vertebra or the whole body may be affected. 
Disease of two vertebral bodies in different non-adjacent parts of the spine has 
been observed. The number of vertebrae involved in the extension of the morbid 
process necessarily varies: in some instances the bodies of twelve or even more 
have been diseased, with a distortion of the whole column. 
The caries is aggravated by the pressure thrown upon the affected 
vertebral body; portions of the diseased bone become absorbed; the 
vertebral body becomes excavated or yields; the spine bends forward 
above the seat of the disease, and backward angular deformity at the 
point of disease results. This extends as more vertebrae are involved : 
the knuckle or projection is seen in the back; this enlarges and the so- 
called “ humpback ” results. This projection is to a certain extent 
modified by compensating curves in the healthy portions of the spine and 
alteration in growth in the shapes of the healthy bodies, and peculiar 
characteristic distortions result. The process may be arrested, the 
development of healthy bone take place, and a natural cure with 
deformity results; or the process may extend beyond the curative efforts 
of the cicatrizing ostitis, and necrosis with caseous foci and abscesses 
may result; which latter, extending to the adjacent tissues, discharge, 
forming sinuses, followed by prolonged suppuration with accompanying 
sepsis. Deformity inevitably results, with death in the severest cases, 
though ultimate recovery may take place even in cases regarded as 
hopeless. The ostitis extends to the adjacent tissue, involving the 
spinal canal and attacking the spinal cord and its membranes, giving 
rise to a pressure paralysis. This is not due to the narrowing or dis- 
torted shape of the spinal canal, except in rare instances, but comes as 
the result of an external pachymeningitis. Inflammatory thickening of 
the dura results; myelitis follows in certain instances, with ascending 
and descending secondary degeneration. The process may arrest itself, 
leaving no permanent change or a slight sclerosis, or the whole cord 
may be reduced to a fraction of its normal size. Paralysis may also be 
caused by the pressure of an abscess, and in rare instances by loose frag- 
ments of bone. In severe cases of angular deformity the chest becomes 
disturbed, with secondary pathological changes in the shape of various 
viscera. The shape and capacity of the chest are very much altered, 
and the ribs sometimes sink into the pelvis or rest upon the crests of the 
ilium. Hypertrophy of the heart may follow. Narrowing of the 
cavity of the aorta has also been noticed by Lannelongue. A cure, 
however, is possible even if the deformity be very pronounced, but the 
correction of a pronounced deformity cannot be effected. 
Etiology.—Authorities differ as to whether the affection is more 96 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
common in males or females. The disease is probably equally frequent 
in the two sexes. It is much more common in childhood, beginning 
at the fifth year in nearly one-third of the cases. Gibney found that 
87 per cent, were under fourteen years of age. It would appear, 
although statistics vary, that the theory advanced by Taylor is a plausi- 
ble one—namely, that the regions most liable to disease are those most 
exposed to jars or increased pressure, and that the disease will be more 
frequent at the hinges of motion in the spinal column or where there is 
the greatest exposure to violent jars. 
The determining cause of caries of the spine is in all probability a 
jar or superincumbent pressure upon a tissue which is incapable of 
resisting slight injury, and which becomes thus exposed to the invasion 
Fig. 32. 
Fig. 31. 
Caries in cervical region. 
Caries in high dorsal region. 
of the tubercle bacillus. Statistics as to an inherited predisposition or 
diathesis would indicate that an inherited lack of resistance is in many 
instances a factor in causation. 
Symptoms.—The symptoms of caries of the spine vary to a certain 
extent according to the portion of the spine affected. They may be 
classified as follows: First, those symptoms which are due to irritation 
of the nerves proceeding from the spine; second, those due to a stiffness 
of the muscles of the back and of the spinal column; third, to peculiar- POTT’S DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
97 
ity in attitudes from the inability of the spine to bear superimposed 
weight. 
Typical cases of Pott’s disease are so characteristic that the diag- 
nosis is evident at a glance from the singular deformity of the back; 
but in the early stages some experience is necessary in recognizing the 
affection. Peculiarity of attitude due to muscular stiffness, referred pain, 
or nervous disturbances are then prominent early symptoms, and may be 
present before a projection has been noticed. The peculiarity of attitude 
is due either to reflex muscular spasm similar to that seen in joint dis- 
Fig. 34. 
Fig. 33. 
Caries in mid-dorsal region. 
Caries of spine, with psoas contraction and old 
sinuses. 
ease, or to an unconscious effort on the part of the patient to prevent 
jar or any increased pressure upon the affected vertebral bodies. This 
attitude necessarily varies according to the point of the spine attacked. 
In the upper cervical region it resembles that of wry neck; in the lower 
cervical or upper dorsal region the chin is held somewhat raised and the 
spinal column below the point of disease is straighter than normal; in 
the middle dorsal region the attitude noticed most frequently is an ele- 
vation of the shoulders, sometimes with one held higher than the other, 
and some lateral deviation of the spine; in the lower dorsal or lumbar 
Vol. II.—7 98 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
region the patient, in the early stage, will be frequently noticed to lean 
backward. The patient walks upon the toes, with the knees bent so as 
diminish the jar of the spine. These peculiarities of attitude vary 
according to the severity of the disease. They may be at one time 
more noticeable than at another. A certain amount of muscular rigidity 
of the muscles of the back will be found on palpation, and it will be 
noticed that children become more easily tired, and after playing for a 
while will desire to lie down, rest their arms upon a chair, or support 
the head with their hands. The amount of muscular stiffness and 
rigidity is, in a measure, an index of the degree of activity of the dis- 
ease. In addition to the spasm of the muscles of the back, the attitude 
is affected by contraction of the psoas muscles and in such cases as pre- 
sent psoas contraction: abscess, beginning or developed, is to be sus- 
pected. In the early stages this contraction is slight, but as the disease 
progresses it may be present to such an extent that locomotion on the 
leg is difficult. Double psoas contraction sometimes occurs, crippling 
the patient. 
Pain may be present in Pott’s disease to a very severe degree, but, 
as a rule, this stage is only temporary, and in some cases pain is entirely 
absent. The pain complained of is not in the back, but is referred to 
the peripheral ends of the nerves in the cardiac, abdominal, or epigastric 
region, or frequently in the thighs and legs. In caries of the cervical 
region it may be referred to the back or to the top of the head. The 
pain is ordinarily slight, aggravated by jar, and may be only occasional, 
but severe attacks accompanied by hypersesthesia are sometimes noted. 
Analogous to these attacks of pain are disturbances of other nerves, 
manifesting themselves in dyspnoea with cyanosis, digestive disturbances, 
nausea, vomiting, and troubles of the bladder. These attacks may sub- 
side, and recur at intervals without apparent cause. Tenderness on pres- 
sure over the spinous processes is rarely present. When tenderness of 
the back is observed, it is more an evidence of functional neurosis than 
of caries. Tenderness of the spine may occasionally be observed in Pott’s 
disease from a general hyperesthesia. This, however, is diffuse and not 
sharply localized. 
Paralysis in caries of the spine may be present at any stage of the 
disease. It is sometimes partial, but may become complete paraplegia. 
Out of 295 patients with caries of the spine, Gibney noted paralysis in 
62. In 189 cases of caries of the upper dorsal or cervical region, paral- 
ysis occurred in 59. In 106 cases of lower dorsal and lumbar caries, 
paralysis occurred in only 3. 
Deformity in Pott’s disease is characterized by the backward projec- 
tion of one or more spinous processes. This is due to the carious dis- 
ease of the vertebral bodies forming the anterior support of the spine. 
The spinal column above the disease falls forward, throwing certain of the 
spinous processes into prominence, and thus causing a projection of one 
or more of them. The adjacent vertebrae become more or less involved 
in the disease or altered in shape from the altered pressure, it being found, 
as a rule, that as the projection is sharper the disease is more acute. The 
deformity tends to increase until either a spontaneous cure results or 
until the carious bone has solidified by cicatrization. The deformity may 
involve the whole of the dorsal region, and cause also an unsightly dis- POTT’S DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
99 
tortion of the chest. This consists of a thrusting forward of the sternum, 
with a projection of the lower portion of the sternum and abdomen, 
giving a contour caricatured in the well-known traditional figure of 
Punchinello. 
Abscess is a frequent complication of Pott’s disease. Caseous foci 
extending from the diseased bone may cause sufficient irritation to form 
an abscess, which, projecting from the vertebral bodies into the thorax 
or abdomen, extends down under the fasciae and comes to the surface in 
various regions. In the cervical region, abscess may point in the throat 
(retropharyngeal) or in the neck. Dorsal caries may develop thoracic 
abscess, evacuating itself in the lung or passing through the muscles and 
pointing in the back or sides. The most common place, however, for 
abscess in Pott’s disease is in the inguinal region or in the groin, passing 
under Poupart’s ligament and developing in Scarpa’s triangle—the classi- 
cal psoas abscess. Before passing through Poupart’s ligament, abscesses 
may accumulate in the inguinal region, dissecting up the peritoneum and 
presenting a large subperitoneal abscess. The contents of such abscesses 
are pyoid or sero-purulent fluid containing caseous masses. Frequently 
calcified or bony spiculse are present, and in some instances the contents 
are cheesy, with but little fluid. Abscesses may be absorbed and disappear. 
In a majority of instances, however, abscesses press to the surface and 
ulcerate through the skin, and thus evacuate their contents. If they 
open spontaneously in such a way as to be completely evacuated, they 
may eventually heal, but in many instances the contents are only par- 
tially discharged. Some caseous matter remains, and, although the 
external opening of the sinus is closed, a later reappearance of the 
abscess may take place. In other instances the discharging sinuses per- 
sist with pent-up pus, and eventually exhaust the patient by the accom- 
panying septic processes. 
Diagnosis.—The early recognition of Pott’s disease is of the utmost 
importance. The diagnosis where marked deformity is present is easy. 
A backward projection of the spinal column from the median line of the 
spine is pathognomonic. The curve in chronic rheumatic arthritis, 
rickets, aneurism, or malignant disease is round, entirely different in 
appearance from the sharper angular projection in Pott’s disease. In 
severe scoliosis the trunk may be as badly distorted as in Pott’s disease, 
but the humpback is a projection of the rotated and distorted ribs and 
not of the spinous processes. 
In examining the patient at an early stage the child should be entirely 
undressed, made to stand upon a table or to walk across the room; the 
position in which the child holds itself, the gait in walking, the attitude 
in stooping to pick something from the floor are to be carefully noted. 
The patient should then be laid upon its face on a table or hard bed, and 
the flexibility of the spinal column tested by lifting the child’s feet and 
legs with the face downward. The child should also be turned upon the 
back. The backward extension of each thigh should be examined to 
determine whether any projection of psoas muscle on either side is pres- 
ent. The abdomen should also be palpated in the inguinal region. 
Where cervical caries is suspected the attitude and movements of the 
head should be carefully noted. The patient should be seated upon a 
lounge or the floor and directed to bend forward so as to touch the toes 100 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
with the hands if possible, and at the same time bowing the head for- 
ward so that the chin should touch the chest. The normal flexibility of 
the spine varies in individuals, and in children it is much greater than 
in adults. The forward and backward flexibility is greatly diminished 
where caries of the spine is present, even at an early stage of the disease. 
Stiffness in rotation of the spine should also be examined by causing the 
patient to turn while the pelvis is firmly held. Where caries of the spine 
in the dorsal region is present stooping forward to pick anything from 
the floor is difficult, and only done by holding the spine in a stiff* posi- 
tion quite characteristic of the disease. This is not true, however, in 
Fig. 35. 
Test for stiffness of the spine: normal flexibility. 
caries in the cervical region except in the more acute stages, at which 
time disease is unmistakable from the presence of other symptoms. 
The peculiarity of attitude in early stages of Pott’s disease may be noted 
as a torticollis, a lateral deviation of the spine, an unusual attitude with 
raised chin and elevated shoulders, bent knees, or an exaggerated back- 
ward bending at the lumbar region, varying with the portion of the back 
affected. 
The seat and localization of the pain and nervous symptoms are cha- 
racteristic, more in connection with other symptoms than from anything 
noticeable in the pain itself. They are ordinarily classed by the parents POTT’S DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
101 
and attending physicians as rheumatic or neuralgic attacks. A grunting 
respiration and frequent belly-ache, continuing at intervals for a long 
period, are both significant. 
The recognition of a projecting knuckle in the earliest stages of Pott’s 
disease is not always easy. In the cervical region the muscles may be 
thick and the projecting spine masked. The sixth and seventh cervical 
spines are normally prominent, and frequently the first dorsal also; the 
last dorsal and the first or second lumbar are often more prominent in 
health than the other spinous processes. These projections, however, 
are not sharp and do not interfere with forward or backward flexibility. 
Any projection of the spine in the middle dorsal region should be 
regarded as a symptom of great significance, as a physiological projec- 
tion of one of the spinous processes in the mid-dorsal region is not 
observed. Peculiarities in the line of spinous processes are to be seen 
in lateral curvature, and in some instances of cancer and sarcoma of the 
spine, in aneurism and rhachitic curves of the spine in small children. 
The first is easily distinguished from Pott’s disease by the twist or rota- 
tion of the spine, while rhachitic curves are rounded. This is also true 
of the spinal curves due to carcinoma, sarcoma, and aneurism of the 
spine. 
The recognition of paralysis is not difficult after it is developed; 
beginning paralysis is sometimes overlooked. It is characterized by 
exaggeration of reflexes, knee-jerks, and ankle-clonus. Abscesses are 
recognized in the early stage by palpation and the recognition of psoas 
contraction. 
Pott’s disease may be confounded with traumatic neuritis of the spine 
(railroad spine), hysterical spine, rheumatoid arthritis, and sacro-iliac dis- 
ease. Other mistakes in diagnosis have occurred, but are due more to 
an ignorance of the ordinary symptoms of Pott’s disease than to any 
inherent difficulty in the diagnosis itself. Mistakes in diagnosis between 
low caries and acetabular hip disease have been made, but can be avoided 
if it is borne in mind that in hip disease flexion in abduction of the lame 
thigh is interfered with, while in caries of the spine motion in abduction 
is as free on the lame as on the other side; and this is usually true of 
flexion. 
A distinguishing characteristic of traumatic neuritis of the spine or 
the neurasthenic or hysterical spine, as compared to Pott’s disease, is 
that in the so-called functional alfections local tenderness in the back is 
usually present, but is almost invariably absent in Pott’s disease. In 
rheumatic arthritis the stiffness of the spine is not sharply localized, but 
involves nearly the whole column; there is usually little muscular 
spasm, no unusual projection of the spinous processes; the ribs are 
ankylosed to the spine, and a full expansion of the chest is interfered 
with or the amount of expansion is noticeably limited. 
Prognosis.—Caries of the spine is necessarily a disease of long dura- 
tion. It involves a severe deformity unless checked, and is attended 
by severe complications, paralysis, and abscess, and at times alarming 
symptoms. Facts, however, show that the disease has a tendency to 
recovery in many cases, but with the development of deformity. Under 
thorough treatment deformity can be prevented, the symptoms relieved, 
and patients entirely cured. Pathological specimens, however, show 102 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
complete bony union and an entire cessation of the carious process, and 
clinical evidence in abundance can be cited to prove complete recovery 
in a large number of instances (Fig. 36). 
In the autopsies at the Munich Pathological Institute on patients with Pott’s 
disease 24 out of 31 were found to have hypertrophy of the right side of the 
heart; 4 had muscular degeneration of the heart-walls; 2 had stenosis of the 
mitral valve; 1 showed acute miliary tuberculosis; 8 died of phthisis, 4 of pneu- 
monia, and 1 of carbuncle. In one of Lannelongue’s specimens of stenosis of the 
aorta following Pott’s disease the aorta only measured 16 mm. at the origin of the 
brachio-cephalic trunk, 12 mm. after the carotid had been given off, and only 8 
mm. in the region of the second lumbar vertebra. In another specimen the lumen 
of the aorta was reduced to a mere slit. 
The prognosis of abscess depends largely upon the situation of the 
abscess and the possibility of complete evacuation. The prognosis in 
adults is not as favorable as in children. 
The tendency of the deformity is to in- 
crease during the period of activity of 
the disease, as well as in the period of 
growth of a twisted spinal column—a 
tendency especially marked in the upper 
dorsal region. Cases of arrest of the 
disease and spontaneous cure without 
marked deformity occasionally occur in 
upper cervical and in lower dorsal dis- 
ease, but in the upper and mid-dorsal 
regions the tendency to an increase of 
deformity is proportionate to the extent 
of the disease. In some cases arrest of 
growth of the whole child takes place, 
apart from the loss of vertebral sub- 
stance. This is especially true in upper 
dorsal disease. A peculiarity in the 
shape of the face is also seen in cases 
with severe deformity of the trunk. 
Paralysis in Pott’s disease shows an 
unusual tendency to recovery. Taylor 
and Lovett found that of 59 cases ana- 
lyzed, 39 recovered entirely, 3 recovered 
in part, 5 died of an intercurrent affec- 
tion, and in 12 the termination was not 
known. Where the bladder and rectum 
were paralyzed the percentage of recov- 
eries was much smaller. The average 
duration of paralysis was somewhat less 
than one year. The disappearance of 
paralysis was gradual, recovery of sen- 
sation appearing first, then that of 
motion. The recurrence of paralysis 
occurred in a few cases. Marked paralysis of sensation indicates an 
extensive myelitis, but some impairment of sensation is found in a 
majority of cases. Paralysis of sensation may be marked, and yet 
recovery result. 
Fig. 36. 
Spinal curvature with exaggerated deform- 
ity : recovery hy ankylosis (Park). POTT’S DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
103 
Treatment.—As the course of Pott’s disease is a long one, treat- 
ment through many years is necessary. The measures used, however, 
vary with the pathological conditions and the activity of the process. 
The principles of treatment of caries of the spine are simple, though 
their practical application is attended with difficulty. The diseased 
vertebral body should be protected from jar and pressure until a cure is 
accomplished. As in ostitis elsewhere, there is an effort toward repair, 
and everything should be avoided which would hinder this reparative 
process. The jars which come upon the spinal column are chiefly those 
received in bending the column forward, and pressure upon vertebral 
bodies comes from the superincumbent weight of the head and trunk. 
In treating a diseased vertebra the superincumbent weight should be 
removed from the part affected as far as is practicable, and all bending 
forward avoided. To prevent deformity the spinal column should be 
made as straight as possible and secured in a straightened position. A 
relapse will occur unless it be supported while the bone is not sufficiently 
solidified to endure a jar without reawakening an ostitis but partially 
healed. If the proper conditions are granted, it is possible to effect a 
cure without a deformity. Although it is sometimes difficult to secure 
the requisite conditions for a sufficiently long time, yet prevention of the 
increase of the deformity in all cases, and even diminution of slight 
deformity in some instances, can be gained by thorough treatment. 
The methods of treatment may be grouped as—first, recumbency; 
second, the use of appliances or corsets. 
Recumbency.—If the patient lie upon the back or upon the face 
on a hard surface, there is no superincumbent weight pressing upon any 
portion of the spine. If the patient lies upon his back upon a sagging 
bed, the spine is bent and some pressure upon the vertebra results, 
though the superimposed weight is removed. For this reason it is not 
sufficient in treating caries of the spine by recumbency that the patient 
be placed in bed: the spine should be held in such a position that the 
forward concavity of the column should be as slight as possible or ob- 
literated entirely. 
The method of treatment by recumbency has certain manifest disad- 
vantages. It is irksome to the patient and the attendant. It removes, 
however, superincumbent weight entirely, and it is therefore of use in 
the acute stage for the purpose of preventing an increase of the inflam- 
matory process, and of diminishing it by lessening the irritation from 
jar and superimposed pressure. 
It will be found in practice that patients who have suffered from attacks 
of neuralgic pain during the painful stage of Pott’s disease, will after a short 
period of thorough fixation become less restless and irritable, will gain in general 
condition, and be free from pain. It is difficult to secure sufficient fixation in 
the recumbent treatment without the use of some form of fixation frame. The 
gouttilre of Bonnet, though admirable in its efficiency, is cumbersome and expen- 
sive. Its advantages can be secured by a light bed-frame, made as follows: Four 
strips of steel bar or four strips of ordinary gas-pipe half an inch in diameter are 
fastened together, making an oblong frame of the patient’s height and width. The 
steel bars can be riveted at the ends or the gas-pipes can be secured in the ordi- 
nary gas-fitter’s rectangular joint. This frame is covered tightly with stout cotton 
sheeting, wound about the frame, made tense, and secured at the sides. If this is 
placed upon a bed, the patient can lie upon it as comfortably as upon the ordinary 
mattress. The patient can be secured to this frame by straps about the shoulders 104 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
and hips and, if necessary, about the knees. The child can be lifted on the frame 
and carried about easily. The sheeting can be changed when soiled; an opening 
should be cut in the region of the buttock, so that the bed-pan can be used. A 
Fig. 37. 
Bed-frame. 
traction adjustment can be added at the ends of the frame. The great advantage 
of this apparatus is that the patient, while thoroughly protected from jar, can be 
Child in bed-frame. 
moved in an appliance that is neither cumbersome nor expensive. In the severest 
cases, in addition to the frame, fixation of the trunk by the employment of a plas- 
Fig. 39. 
Child in bed-frame, with head traction. 
ter jacket or corset is sometimes advisable to secure the patient from any twisting 
in sleep. In ordinary cases, however, the frame alone is sufficient, but the use of 
pads placed under the back, pressing the spine forward, is of advantage. These POTT’S DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
105 
pads can be made of saddler’s felting, and should be of sufficient thickness to 
raise the projecting portion of the spine. They should be placed at each side of 
the spinous process, and can be secured to the sheeting to prevent slipping. In 
cervical or high dorsal caries a light traction upon the head is of advantage. This 
can be made by a head-string fastened to the patient’s head and secured to the 
top of the frame or to a weight-and-pulley attachment at the head of the bed ; 
counter-pull is furnished by a belt secured to the lower part of the frame, or, if a 
weight and pulley is used, by raising the head of the bed. 
Treatment by Plaster Jacket.—The most ready method of treatment of 
caries of the spine is by the plaster jacket 
introduced by Dr. Sayre. The advan- 
tages of this method are its ready applic- 
ability, its cheapness, and the fact that it 
places in the hand of every practitioner 
an efficient means of treatment. It can- 
not be said, however, that a plaster jacket 
is applicable to all cases of caries of the 
spine. It is a method which can be used 
with benefit in suitable cases. Some 
skill is required in application. A poor 
jacket does harm rather than good, and 
deceives the patient and the physician. 
In applying a plaster jacket the patient 
should be placed in the recumbent posi- 
tion or else in as straight a position as 
possible, with the curve corrected as 
much as practicable by suspension. 
Plaster bandages prepared in the usual 
way are wound around the patient’s 
trunk, with the patient kept in a cor- 
rected position until the plaster has 
become hard. When the disease is situ- 
ated in the mid-dorsal region the patient 
is firmly supported by this means. In 
the cervical or high dorsal region a plaster jacket is of use simply as a 
base for the support of some form of head-retention. The simplest 
Fig. 40. 
Jury-mast for high dorsal and cervical 
caries. 
Fig. 41. 
Frame for application of plaster jackets in recumbent position. 
of these is what has been termed a jury-mast, which consists of a bent 
steel rod serving as a support for a head-sling. Instead of the jury- 106 
INJURIES AND SURGICAL DISEASES OE THE SPINE. 
mast, which is unsightly, an arrangement can be used supporting the 
head beneath the chin and occiput which is less of a disfigurement. In 
lower lumbar caries, where much lordosis is present, a plaster jacket 
Fig. 42. 
Application of a plaster jacket in the recumbent position. 
should be applied, with the patient’s back hollowed slightly in a position 
of lordosis and with but slight suspension to diminish to a minimum 
the intervertebral pressure. 
Fig. 43. 
Apron for antero-posterior support. 
During the application of the plaster bandage the patient should either be sus- 
pended by the head or arms, or both, or a plaster jacket can be applied with the 
patient recumbent, lying face downward upon a tight sheeting support, like a flat POTT'S DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
107 
hammock. The hammock, made of stout sheeting, can be made tense by means of 
pulleys, and if slit, as is recommended by Brackett, along the patient’s sides, the 
surgeon can apply plaster bandages snugly. When these are hard, the sheeting 
hammock is cut and can be pulled out from beneath the jacket. 
The details of the application of the plaster are of importance. Projecting 
spinous processes or bony portions of the pelvis are to be protected by saddler’s 
felt placed at both sides of the bony projection. The plaster should be well 
rubbed into crinoline free from glue or sizing, which will delay the setting of the 
plaster. The bandages should be well rubbed in as they are applied, and should 
be applied after having been thoroughly wet. If the details are properly attended 
to, the bandages become hard in a few minutes. Proper material should be used 
tor the bandages. Cloth with too close a mesh cannot retain a sufficient amount 
of plaster, and holds moisture too long to admit of rapid hardening. Too coarse- 
meshed cloth, while allowing rapid setting, makes a jacket which is liable to 
crumble. 
Plaster jackets are to an extent uncleanly, and for that reason uncomfortable; 
and occasionally an eczema will develop under the jacket, abscesses or chafes may 
be present, without attracting the immediate attention of the surgeon; but these 
Fig. 44. 
Fig. 45. 
Thomas collar for cervical caries. 
Head-ring, front view. 
difficulties are to an extent obviated by skilful application and frequent renewal 
of the jacket. A plaster jacket can be split and lacing-hooks fastened to the sides 
of the cut, and the corset removed and reapplied at pleasure. This, however, does 
not furnish as firm a support as the unsplit bandage, and should not be used except 
in convalescent cases. 
As a substitute for split plaster jackets, and their superior in durability, a cor- 
set of leather or paper can be made. This is shaped upon a cast taken from a plas- 
ter jacket used as a mould. Sole leather is wet, stretched, and hammered upon 
this cast, and thoroughly dried; if necessary, it can be strengthened by steel 
strips and fastened with the requisite lacings. Paper jackets are made by pasting 
upon the cast with white paste strips of thick matrix-paper thoroughly wet. 
Four to six layers of this paper are used; between each two layers strips of 
crinoline or linen are added, with a layer of crinoline inside and outside: the 
whole should be dried thoroughly, and the resulting corset split and removed 
from the cast. It can then be painted and varnished, and forms a stiff light 
jacket. Another form of jacket is made by the use of thin strips of wood fastened 
by glue. Corsets have been made of strips of steel woven wire and of aluminum. 
The latter are expensive, and hardly more serviceable than those of paper or 
leather. 108 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
Treatment by Means of Braces.—The treatment by means of braces 
has fallen into discredit from the fact that the application of spinal 
supports has been left too often to mechanicians whose object is more 
to sell their appliances than to cure the patient. Furthermore, the 
proper application of braces requires some experience and skill and 
attention to detail. 
The brace consists of a strong steel support which is fitted to the back when 
the patient is recumbent, lying upon the face with a straightened spine. To this 
the patient is fastened by an apron carefully fitted in the front and secured to the 
brace behind by straps and buckles. 
The uprights of the brace lie on both 
sides of the spinous processes, and pads 
secured to a firm pad-plate are fastened 
to the uprights at such points as will 
bear the greatest pressure when the 
patient is erect. It will be seen after 
the patient is firmly secured, while in a 
recumbent position, to a firm steel brace, 
that in an erect position the amount of 
forward bending will be slight, the pro- 
jecting portion encountering the resist- 
ance of a firm and unyielding brace. 
The successful employment of braces 
depends upon the careful attention to 
detail in the way of proper straps, pads, 
and buckles. The brace should be 
altered from time to time as the patient 
alters in shape. It will be readily seen 
that the stiffness of the brace should be 
sufficient to sustain a possible forward 
bending of the spine. Braces are often 
made light, allowing some spring, thus 
impairing their usefulness. It should 
be remembered that all possible forward 
bending increases the jar upon the 
affected vertebral bodies, and therefore 
is to be avoided. The attempt should 
be made to transfer, as far as is possible, 
the weight upon the articulating pro- 
cesses rather than upon the bodies. In 
the upper dorsal and in the cervical 
regions proper attachments are neces- 
sary for the support of the head. These attachments either consist of a jury-mast 
or, better, a circular ring or collar, which supports the head. When properly fitted 
these appliances are not unsightly, but their proper adjustment needs care. 
Fig. 46. 
Wire head-support attached to antero-posterior 
splint for cervical and high dorsal caries. 
Selection of Method of Treatment.—It should be clearly borne in 
mind that no one form of treatment is applicable to all stages of a dis- 
ease nor to all cases. In the selection of the method of treatment the 
pathological condition should be carefully considered. In the acute stages 
absolute and complete recumbency should be enforced, and in such a 
position as will not only relieve the weight from the affected vertebral 
bodies, but diminish the pressure as far as possible. In the subacute and 
convalescent stage the erect position, which is essential for health, and 
therefore for the establishment of a reparative process, should be allowed, 
but only allowed when the back is firmly fixed in such a position as will 
as nearly as possible prevent any additional jar on the unsound verte- 
bral bodies. Whether that should be done by some form of corset or 
of brace depends upon the amount of nursing facilities at the disposal POTT’S DISEASE; SPONDYLITIS; VERTEBRAL CARIES. 
109 
of the patient. Braces require more attention and more care. They 
are more precise, and therefore better, than a corset. In the mid-dorsal 
region, however, a carefully applied plaster jacket gives a support which 
is both firm and convenient, and requires no especial nursing. In the 
cervical and upper dorsal region braces are more effective than the cor- 
set and jury-mast, but require some skill in proper adjustment. 
Treatment of Complications.—Lumbar and iliac abscesses constitute a 
formidable complication. Authorities differ as to the relative advan- 
tages of expectant treatment over that of early operation. The facts are, 
that a certain number of cold abscesses in the spine become absorbed if 
Fig. 47. 
Fig. 48, 
Antero-posterior support: back view. 
Anteroposterior support with head-ring for 
high dorsal caries : side view. 
the carious process is arrested. In a certain number the contents tend 
to evacuation, and, if they can be thoroughly reached with the knife 
and suitably drained, this should be done. If, however, they are in a 
region where drainage by spontaneous opening is more thorough than 
that given by early operation, the expectant treatment should for a time 
be employed. Where abscesses become large they need to be opened, 
and this should be done by a free incision under aseptic precautions. In 
lumbar abscesses the opening should be made in front and back by an 
incision in front, above Poupart’s ligament, near the anterior superior 
spine, and behind in the region between the ribs and iliac crest. 110 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
The Treatment of Psoas Contraction.—This deformity should be 
treated by correction under an anaesthetic or by traction by means of 
weight and pulley. In resistant cases osteotomy may be necessary. 
Paralysis.—The natural course of paralysis is toward recovery, and 
the use of medication is therefore of uncertain value. The same is true of 
the actual cautery, recommended by the earlier writers. I n some instances 
laminectomy is of advantage, but exact value of this procedure in Pott’s 
disease is not as yet determined. In view of the fact that the percent- 
age of recovery of cases properly treated is nearly 100 per cent., the 
advantages of laminectomy can only be urged where thorough treatment 
has been tried and failed, where care cannot be furnished for a sufficiently 
long period to establish a cure, or where the patient is becoming worse 
after a long period of careful treatment. 
Acute Osteomyelitis of the Vertebra. 
This affection, which differs clinically from tuberculosis of the verte- 
brae or Pott’s disease, has been described by Tournadour, Lannelongue, 
Witzel, Stanley, Konig, Valleix, Huron, Deaver, Lloyd, Chipault, 
Morian, and Keen. The invasion is, as a rule, more violent than in 
caries; there is more fever and muscular spasm of the muscles of the 
back ; later there are swelling and suppuration. In a third of the cases 
the arches are attacked. In the cervical region the head may be drawn 
back as in cerebro-spinal meningitis; later there are swelling and pain in 
the region of the spine. In some cases there is paralysis of some of the 
limbs, varying with the portions of the nerves attacked. 
Diagnosis is not always easy in the early stages. Where it is pos- 
sible for a diagnosis to be made the treatment by direct incision, disin- 
fection of the parts affected, and drainage, recommends itself. In many 
instances, however, the expectant treatment is necessary from an inability 
to recognize the disease. The disease is a dangerous one, but spontane- 
ous recoveries have been reported. 
Cases have been reported by Gibney, and also by Osier, with symp- 
toms referable to disease of the spine following typhoid fever. The 
“ typhoid spine,” as it is termed by Gibney, is perhaps an osteomyelitis 
following typhoid fever, or an affection resembling osteomyelitis with less 
acute invasion than in the instances hitherto reported. (Hide Volume 
I. Chapters XIV. and XXXV.) 
Curvatures of the Spine not Due to Primary Bone Disease. 
In addition to what is termed angular curvature or Pott’s disease, 
already described, there is common a lateral curvature or scoliosis, in 
which the spinal column is distorted by curves due to faulty habits in 
attitude, paralysis, or weakness of muscles. These curves are termed 
kyphosis (the curvature with a convexity backward) and lordosis (curve 
with a convexity forward). Strictly speaking, the angular curvature in 
Pott’s disease is a form of kyphosis, but the term also includes other 
more common curves, especially the deformity known as round shoul- 
ders. This affection is usually the result of bad habits in standing and 
sitting, due either to muscular weakness, occupation, or in some instances CURVATURES NOT DUE TO PRIMARY BONE DISEASE. 
111 
to near-sightedness. In rapidly-growing children the muscles of the back 
have not the required strength to maintain for a long time a correct posi- 
tion : the arms and scapulae drop forward, and in order to balance this 
altered weight the patient leans backward at the waist, protrudes the 
belly, and throws the head somewhat forward, giving a stooping attitude. 
The same result is produced by those whose occupation obliges them to 
maintain a stooping position for many hours in the day. 
In children with rickets or paralysis, owing to the weakness of the 
muscles a kyphotic attitude is assumed in a sitting position. In rheu- 
matoid arthritis and osteomalacia, and 
sometimes in malignant diseases of 
the spine, the spine is arched back- 
ward. 
In the early stages of curvatures 
without alterations in the shape of 
the bone, the spinal column can be 
made straight with but little difficulty. 
After a time, however, the bodies of 
the spine become altered, the liga- 
ments adapt themselves to an abnor- 
mal position, and the curve becomes 
a fixed one. 
In the early stage of round shoul- 
ders the curvature can be corrected 
by drilling the patient to maintain a 
correct attitude. If there be muscu- 
lar weakness, special gymnastic exer- 
cises are of importance. Appliances 
are, as a rule, not advisable except in 
Pott’s disease. 
Lordosis.—The forward bending 
of the spine (convexity forward) oc- 
curs as a deformity often secondary 
to other conditions, such as congenital 
dislocation of the hip. It may result, 
however, from simple weakness of 
the erector spinse muscles. The 
patient assumes this position in order 
to balance the trunk in such a way 
that the weakened muscles are not 
called upon to act. This is also seen 
in pseudo-muscular hypertrophy. It is seen also in early symptoms in 
Pott’s disease and in children with large abdomens. Patients with 
ascites or abdominal tumors, as well as pregnant women, assume 
naturally this position. When the deformity exists in a mild form, due 
to a muscular weakness from overgrowth or from any non-organic cause, 
it is benefited by gymnastic exercises for the purpose of developing the 
lumbar muscles. In some instances a back-brace or a removable corset 
is of advantage to relieve the patient from the strain of the erect posi- 
tion, but it should only be used in exceptional cases and for a short time. 
Massage and electricity are useful as adjuvants. 
Fig. 49. 
Spondylitis deformans, or rheumatic arthritis 
of spine. 112 
INJURIES AND SURGICAL DISEASES OF TIIE SPINE. 
Spondylolisthesis.—This term is applied to a rare affection which 
consists of the dislocation forward of the last lumbar spine where it 
articulates with the sacrum. A few cases of this has been reported. 
They were the result of the relaxation of ligaments after confinement. 
The use of a stiff corset and the employment of crutches constitute the 
treatment. 
Spondylitis Deformans. 
This name is given to chronic rheumatoid arthritis of the vertebral 
articulations. It is characterized by stiffness of the spine and a curva- 
ture with the convexity backward. In many instances it is accompanied 
by ankylosis of the articulations between the ribs and the spinal column, 
and in many, but not all, instances by rheumatoid arthritis in other 
joints. The affection is more common in old age, but is occasionally 
seen in children. It is to be distinguished from Pott’s disease by the 
fact that the stiffness is not narrowly localized, and from a characteristic 
rounding in the curve, which is entirely different from the angular or 
sharp curve in Pott’s disease. (Vide Fig. 49.) 
The prognosis is not favorable. 
The treatment is similar to that in use for chronic rheumatoid 
arthritis elsewhere. 
The operations which have been performed and recommended on the 
spinal column may be grouped as follows: 
A. Laminectomy: 
1. To enter the canal, open the dura, and examine the injured cord 
and relieve the pressure of hemorrhage in case of hemorrhage ; 
2. For the reduction of dislocation of the vertebrae or removal of 
spiculae; 
3. For the removal of any tumor of the dura or any foreign body 
pressing upon the cord ; 
4. As a means of examination and exploration of the vertebral 
bodies in Pott’s disease. 
B. Operation upon the sacrum and coccyx. 
C. Vertebral puncture for the relief of excess of cerebro-spinal fluid. 
Laminectomy.—The object of this operation is to relieve the spinal 
cord of any pressure which may be exerted upon it, with the least pos- 
sible mutilation of the tissues involved in its structure. The indications 
for this operation have already been spoken of under the headings of 
Fracture of the Spine, Pott’s Disease, and Spinal Tumors. The tech- 
nical details, however, need special attention. 
The dangers of laminectomy are chiefly those to be encountered from the depth 
and importance of the tissues and structures attacked. Horsley has called atten- 
tion to the dangers of hemorrhage, and Keen lays special stress upon the shock 
following the operation. Especial care should be taken in administering the anaes- 
thetic. The patient should be brought to the edge of the table, so that the face 
should project, and placed upon the belly or nearly so, with the face turned to the 
side, giving the anaesthetizer an opportunity to thoroughly inspect the face. 
Incisions of different shapes have been recommended. A long, straight, median 
Operations upon the Spinal Column. PLATE V. 
Osteoplastic Resection of Posterior Vertebral Arches. (Urban.) OPERATIONS UPON THE SPINAL COLUMN. 
113 
incision is, however,sufficient in all cases,unless an osteoplastic resection is attempted, 
when an inverted U-shaped incision is advisable. ( Vide Plate V.) The skin, mus- 
cles, and fasciae are to be divided, the spinous processes and arches laid bare: the 
muscles are to be separated from the arches by a knife rather than by raspatory. 
Time is not to be lost by the use of haemostatic forceps unless large vessels are 
divided, which is ordinarily not the case. Hemorrhage is to be controlled by 
packing the wound, by pads, or by hot water. Osteoplastic resection, although 
advocated by some, is not to be recommended; the subperiosteal division, being 
shorter, is preferable. After the spinous processes and the arches are cleared 
attempts should be made to remove the bony tissue. For this purpose the saw, 
forceps, mallet and chisel, and the trephine have been used, but the simpler the 
Fig. 50. 
Specimen of laminectomy of spine (Warren Museum). 
method the better. The periosteum is to be pushed back from the spinous pro- 
cesses and arches as far as possible, and by the use of a pair of strong bone-forceps, 
made for the purpose with a flat plate on the under side, the arches are to be di- 
vided on each side, care being taken to avoid wounding the dura or the nerves as 
they emerge from the spinal column. It is necessary to remove several laminae, 
the size of the opening into the canal depending upon the amount of the cord it 
is necessary to expose. Fatty tissue will be found lying in the canal. It can be 
separated by blunt dissection; the dura is freed from the canal by means of a 
director, and the cord felt through the dura. In case of extradural lesions, these 
can be inspected, and the condition of the dura and the contents of the spinal 114 
INJURIES AND SURGICAL DISEASES OE THE SPINE. 
canal determined. It is advisable, if possible, to avoid opening the dural cavity. 
When it is necessary the incision of the dura should be a straight, median incision. 
After the operation, in case any is needed, the dura should be closed by sutures, 
the muscular flaps brought together, and the skin sutured. It is advisable to drain 
the wound for a few days by means of a gauze wick, as considerable oozing follows 
the operation. No drain, however, should be inserted within the canal. In some 
instances it is desirable to suture the muscles and ligaments. A bed-frame after 
the operation, or a fracture-bed, will be found of assistance. Patients lie most 
comfortably upon the back after the operation: lying upon the face facilitates 
attention to the wound and obviates the necessity of turning the patient for that 
purpose, but does not permit of as complete drainage of the wound as a position 
upon the back. 
Attempts have been made to reduce the deformity following fractures or dislo- 
cations by cutting down upon the spinal column and forcing the displaced frag- 
ments into position; but such a procedure is of doubtful efficacy. Spiculse of 
bone can be removed—the condition of the bone examined. Correction of the 
malposition is to be effected when possible with much circumspection to prevent 
further injury of the cord or nerves. 
Laminectomy in Pott’s Disease.—The spinal canal is opened in caries 
of the spine to relieve the cord from pressure, and laminectomy for that 
purpose does not differ from the ordinary procedure. It has also been 
recommended as a means of examining the condition of the vertebral 
bodies. This can be done by separating the dura from its bony attach- 
ment in the canal, using a curved director for the purpose, and explor- 
ing the posterior surfaces of the vertebral bodies by means of a probe 
or director, pushing the dura and cord gently to one side. It is not 
always necessary that a complete laminectomy should be done for this 
purpose : opening the canal by removal of the arches on one side will 
be sufficient unless more room is required. 
Measures have been recommended for the examination of the vertebral 
bodies without entering the vertebral canal. This is of value in wounds 
of the spinal column without injury to the cord for the examination of 
the bodies in tubercular ostitis, as well as in osteomyelitis. The tech- 
nique varies in different parts of the spinal column—viz. in the lumbar 
region, in the dorsal, and in the cervical region. 
Lumbar.—This procedure was described by Treves in 1884 as 
follows: 
A straight incision is made from the last rib to the ilium, 2J inches 
to the outside of the median line; the incision reaches to the border 
of the quadratus muscles, and the tips of the transverse processes 
should be felt; careful dissection should be continued down to the psoas 
muscle. The peritoneal cavity is not to be opened. By means of large 
retractors, such as are used in nephrectomy, the wound can be explored 
at its lowest depth, and by blunt dissection the side and anterior surface 
of the bodies examined by the huger. 
Dorsal Region.—Boeckel in 1882, Hartman, Vincent, and others, 
have all recommended similar operations in the dorsal region. Schaeffer 
advises an incision to the side of the line of the spinous processes, which 
uncovers the tip of the transverse processes of the affected vertebrae and 
the head, neck, and part of the body of the corresponding rib. To 
avoid wounding the pleura, sympathetic ganglia, the spinal nerves, and 
the intercostal arteries, the rib is to be divided at the level of the tuber- 
osity. The transverse processes are then to be removed, the bone being 
free from either attachment by blunt dissection. Vincent has suggested OPERATIONS UPON THE SPINAL COLUMN. 
115 
boring from the side through the carious vertebral body and passing 
drainage through this opening. 
Cervical Region.—It lias been recommended to attack the vertebral 
bodies in the cervical region through the mouth. There are manifestly 
objections to this plan. The lateral method is much preferable; this 
can be done in the following way : An incision is made on the posterior 
border of the sterno-mastoid, the length depending upon the depth of 
the region to be attacked. The superficial veins and nerves are to be 
avoided as far as possible. The sterno-mastoid and omo-hyoid are to be 
raised, and the space bounded by the splenius, omo-hyoid, and posterior 
scalenus is reached; the longus colli is to be dissected through. Great 
care must be taken to avoid the vertebral arteries and nerves. Another 
method has been suggested, which consists of the incision at the level 
of the larynx, passing down to the lateral edge of the thyroid body 
close to the larynx, dividing the tissues internally to the common carotid. 
A small retropharyngeal opening is made, and this is gradually dilated. 
The first of these methods is manifestly the better. 
Wiring' of the Spine.—Wiring of the spinous processes has been 
recommended and performed by Hadra. Ligature of the transverse 
processes, tying together of the laminae, suture of the spinous processes, 
have also all been recommended after laminectomy and in cases of frac- 
ture, but have none of them found general acceptance. 
Operations upon the Sacrum.—Operations for the opening of the 
spinal canal have been all recommended in the sacro-coccygeal region, 
but in this region a gouge, chisel, and mallet are to be used instead of 
the bone-forceps. 
A long incision is made from below the twelfth rib, parallel to the median line 
of the sacrum ; the bone is chiselled through, and the anterior surface of the canal 
explored by means of the finger. The coccyx and lower part of the sacrum can 
be removed, piece by piece, using the .rongeur forceps. The lower three pairs of 
nerves may be sacrificed if necessary, but the upper sacral nerves supplying the 
pelvic organs must not be touched. The operation is a tedious one, and there is 
much oozing of blood. 
Removal of the Coccyx.—This operation is performed in obstinate 
cases of coccygodynia—i. e. painful or irritable coccyx. A median incis- 
ion is made, the bone exposed, and the articulation of the coccyx with 
the sacrum cut through. The plexus of veins immediately beneath 
the coccyx is to be avoided as well as the rectum. The bone can be 
removed subperiosteally. 
Vertebral Puncture.—This has been recommended by Quincke for 
the relief of pressure from an excess of cerebro-spinal fluid. A small 
trocar is thrust into the subdural space in the lumbo-sacral region, 
between the transverse arches or between the spinous processes of the 
adjacent vertebrae. In children the space between these parts of the 
adjacent vertebrae is comparatively large. The point of election is the 
third, fourth, or especially, the fifth, space in the lumbar region. The 
needle is directed toward the median line, entering outside of it—in 
children at the level of the space, and in adults at the tip of the spinous 
process. The first few drops of the fluid are slightly tinged with blood, 
but the remainder is clear. From 20 to 100 c. c. should be drawn oil* 
in an adult, and from 2 to 50 in a child. Rigid antiseptic precautions 
are necessary. The wound should be closed by iodoform collodion. 116 
INJURIES AND SURGICAL DISEASES OF THE SPINE. 
Fiirbringer has tapped the vertebral canal in 86 cases, making the puncture in 
the second, third, or fourth intervertebral spaces in the lumbar part of the spine, 
using no anaesthetic, withdrawing as much as 110 c. c. of fluid in some cases: 37 
of the cases were tubercular meningitis, and there Avas little benefit from the pro- 
cedure. In serous meningitis temporary improvement followed the puncture. 
The procedure does not appear to be injurious, but is only of temporary benefit. 
Tumors of the Spine. 
The spinal column may be attacked by malignant growths in the 
same way as are other tissues. These tumors are those which either 
originate in the bone-tissue of the spine or in the adjacent tissues (Plate 
VI.). 
Primary tumors of the spine are of the class which develop from 
connective tissue, such as fibroma, chondroma, myxoma, lipoma, sar- 
coma, and osteoma. Secondary tumors are those which come by meta- 
stasis, chiefly carcinoma, which is never primary. 
Osteomata usually arise in the periosteum, though exostoses may develop 
directly from the bone. Fibromata usually develop from the periosteum, and 
exceptionally from the marrow. Chondromata and myxomata develop either 
from the periosteum or the soft bony tissue. There are many varieties of sar- 
comata of the spine—central, small round-celled, and chondro-sarcomata. Angei- 
omata are very rare. Osteomata usually are solitary tumors, but others may 
develop in different foci. 
Diagnosis of tumors of the spine can only be made after they have 
become so extensive as to be felt on palpation, or to have caused enough 
destruction of bone-tissue to interfere with the erect position, or to press 
upon the spinal nerves or the cord, causing obstinate neuralgia and 
paralysis. 
The symptoms may resemble those of caries of the spine, and 
there may be a rounded projection of a few spinous processes. 
Caries of the spine is most commonly a disease of childhood, the 
reverse being true of tumors of the spine in most instances. 
Congenital Tumors of the Sacrum. 
In addition to the tumors classed as spinse bifidse, or congenital cysts, 
there is a rare class which consists of vestiges of an attached foetus. 
This varies greatly, from an ill-defined mass of tissue to a more or less 
completely developed structure like a dwarfed or deformed leg project- 
ing from the sacrum. This can be amputated unless so firmly united 
with the pelvis that such an undertaking would be fatal. ( Vide Vol. I. 
Chapter XXVI., Dermoids.) 
Sacro-coccygeal Tumors at the Junction op the Coccyx 
with the Sacrum. 
The most common form of these are varieties of spina bifida, already 
mentioned. They present themselves, however, in some instances 
slightly to the side of the median line. They are not always fluctuating, 
and may be dense, though it is characteristic of them that they vary in 
size from time to time. They are usually mistaken for fatty tumors, as 
in many instances they are covered by a thick layer of fat. Operative Sarcoma of the Spine and Cord. (Goldthwait.) 
PLATE VI. TUMORS OF THE SPINAL CORD. 
117 
interference with these cysts is too often fatal, owing to the difficulty of 
securing complete asepsis, from the constant escape of the cerebro-spinal 
fluid. Dermoid tumors originating in the embryonic remains of the 
post-anal gut have been already considered in Chapter XXVI. Vol. I. 
Of the various malignant growths which develop in the cord proper 
or its membranes, gliomata are the most commonly met, though fibrom- 
ata, sarcomata, glio-sarcomata, and angeio-sarcomata are all reported, but 
very rarely. Multiple fibromata have been observed simultaneously in 
the cord and the peripheral nerves. Fibromata are usually round, and 
give rise to more or less degeneration of the substance of the cord in 
their immediate vicinity. Gliomata constitute tumors of oblong shape. 
They are usually situated around the central canal. Their substance is 
sometimes firm, though usually delicate, and they frequently contain 
cavities. They are sometimes rich in vessels. 
Tumors of the Pia and Arachnoid.—Osteomata occasionally pre- 
sent themselves as small white disks. Angeiomata, from varicose enlarge- 
ment of the veins, sometimes exert pressure on the cord and nerve-roots. 
Tumors of connective-tissue origin may also be seen in the pia as 
primary affections, while secondary growths, carcinomata, may rarely be 
found. As tumors in the spinal canal are confined in an unresisting 
cavity, they are of importance even when small, and their early recog- 
nition is essential for successful surgical interference. 
The symptoms from tumors of the spinal cord vary greatly in their 
location, and according to whether they arise from the centre of the cord 
or from the dura and press upon the cord. Pain is usually present as 
an early symptom, but is not severe, and is frequently mistaken for 
rheumatism. This is accompanied by a certain amount of muscular or 
sensory paralysis. The pain increases pari passu with the tumor. It 
is rarely symmetrical, and in extradural tumors is always unilateral. 
Sometimes in tumors of the cord muscular spasm may be present in 
addition to pain, though this is a symptom which is more commonly 
seen in intradural growths. Horsley has called attention to the import- 
ance of the fact that the pain is not situated at a higher level than the 
tumor, and may be some distance below—a fact of importance in deter- 
mining the point of opening the spine in operation. Tenderness at the 
seat of the tumor is frequently present, but in the dorsal region the ten- 
derness is at a lower level than the tumor. Rigidity of the muscles of 
the spine may exist if the growth of the tumor cause irritation. 
Tumors of the Spinal Cord. 
Tumors growing in the cord present a gradual development of symptoms. 
There is first motor paralysis, later sensory paralysis preceded by pain. The pain 
is at first neuralgic and lancinating; anaesthesia and pain in the lower limbs 
ascend gradually from the feet toward the trunk, and there is a dull ache in 
a distinct portion of the spinal column, accompanied by weakness at that point, 
which is increased on fatigue. The reflexes, deep and superficial, are exagger- 
ated, and eventually lost, with symptoms of descending degeneration and wast- 
ing as the cord becomes diseased. The reflexes, as well as the pain and anaesthesia, 
begin in the plantar region and pass upward. The symptoms are not symmetrical, 
but are unilateral. Spasms and rigidity are present; the pupils are not affected. It 
should be borne in mind that there is a gradual loss of sensation or motion with 
intramedullary growths, while in the extramedullary growths the symptoms of 118 
INJURIES AND SURGICAL DISEASES OF TIIE SPINE. 
pain and spasm indicative of irritation may precede the paralysis. If the paraly- 
sis be of gradual development, preceded by long-continued symptoms of nerve- 
irritation, beginning on one side and gradually transferred to the opposite side, a 
probable diagnosis of compression of the cord by a pressure outside the cord can 
be made. 
A diagnosis of the different varieties of tumor which may be de- 
veloped in the spinal canal is clinically impossible. For the surgeon it 
is necessary simply to determine whether there exist any pressure upon 
the cord, and if this pressure be external to the membrane and capable 
of surgical relief, or a growth of the cord itself and inoperable. 
The successful removal of tumors of the spinal cord belongs to the 
rarer feats of surgery, the difficulty lying not so much in the removal 
of the tumor as in the recognition of the affection at so early a stage 
that relief is possible. Chipault has collected 22 cases of operation on 
spinal tumors; Keen reports 3 more. The result of these operations 
was 11 deaths, 11 recoveries, and the result in 3 is uncertain. The 
operation is essentially a laminectomy, already described, plus the enu- 
cleation of the growth. 
CoCCYGODYNIA. 
This name is applied to a painful affection of the coccyx, which in some 
instances arises spontaneously, but frequently dates from an injury, such 
as a fall or a blow, or comes on after childbirth. It is almost entirely 
confined to women, and usually appears in persons of a neurotic tem- 
perament. In many instances an irregularity in the coccyx can be found 
on palpation. 
The treatment should be at first that which is found efficacious in 
neurasthenic patients—massage, electricity, and stimulants to the circu- 
lation, such as an application of heat and cold, besides general tonics ; 
in more obstinate cases removal of the coccyx is necessary. ( Vide Ope- 
rations upon the Spine.) 
SURGERY OF TIIE PERIPHERAL NERVOUS SYSTEM. 
Surgery of the Nerves. 
Most of the affections of the nervous system belong strictly to the 
domain of internal medicine. There are, however, certain diseases 
which should be considered, in part, in a surgical treatise, from the fact 
that they are relieved by surgical interference. These are divided as 
follows: 
I. Wounds and injuries to the nerves. 
IT. Diseased conditions calling for surgical interference, 
mainly— 
(1) Neuralgia; 
(2) Muscular spasm. 
Wounds and Injuries to the Nerves 
Contusions of the nerves are not uncommon, either in dislocation or 
fracture or from direct violence crushing the tissues. Constant pressure, WOUNDS AND INJURIES TO THE NERVES. 
119 
as in the use of crutches (“ crutch paralysis ”), or lying in a peculiar 
position with the arms under the head for a long period, as occasionally 
happens in intoxicated persons, sometimes produces changes which may 
be classed as injuries. An injury of the nerves is recognized from the 
resulting impairment in the function of the nerve—i. e. motor or sensory 
paralysis. 
All nerves are liable to injury, but lesions of a few nerves may be 
mentioned as not uncommon. 
The facial nerve is often injured in fractures, gunshot wounds, or incised 
wounds, operations for removal of tumors, and blows. This is easily recognized 
by the appearance of the face: the eyebrow cannot be raised nor the eyelids 
entirely closed ; the ala of the nostril on the paralyzed side does not move in res- 
piration, and control of the angle of the mouth is diminished; the patient cannot 
whistle ; the face on the paralyzed side is expressionless. The ulnar nerve is not 
infrequently divided above the wrist or at the elbow or in the upper arm. The 
flexor carpi ulnaris, the flexor profundus in its inner half in the forearm, and the 
whole group of the hypothenar muscles of the hand and the two ulnar lumbrical 
muscles, the interossei muscles, the adductor muscles of the thumb, and half of the 
flexor brevis pollicis are paralyzed. These muscles waste, and there is an atrophy 
of the hypothenar and a partial wasting of the thenar eminence. The position of 
the hand is characteristic, and what is termed a claw-hand results. The sensation 
following injury of the ulnar nerve varies. As a rule, the ulnar portion of the skin 
of the hand on the front and back, the little finger, and the ulnar half of the right 
finger are affected in injury to the ulnar nerve. 
The median nerve, when injured, is chiefly disturbed above the wrist. 
The motor symptoms of injury to the median nerve involve all the 
flexors and pronators of the arm except the flexor carpi nlnaris and the 
ulnar half of the flexor profundus. If the median nerve has been 
divided high up, there will be paralysis of the muscles of the thumb 
except the adductor and half, of the flexor brevis pollicis ; the hand can- 
not be pronated by muscular effort; flexion of the thumb is lost, and 
the thumb cannot be pressed to the other fingers. There is more wast- 
ing of the forearm than in ulnar paralysis. There is no atrophy of the 
hypothenar, but there is of the thenar eminence. The anaesthesia includes 
the radial half of the thumb and palmar surface of the index and middle 
fingers and the radial side of the right thumb. 
The radial nerve is rarely divided, and, as it is a sensory nerve, the sensation 
when the nerve is injured is imparted over the metacarpal bones and first pha- 
langes of the thumb and fore finger. 
The musculo-spiral nerve may be frequently injured in fractures of the upper 
arm or in gunshot wounds. The supinator longus muscle is paralyzed if the nerve 
be injured above the origin of this muscle, and wrist-drop results. 
The sciatic nerve is rarely injured except in gunshot wounds. The external pop- 
liteal branch has been divided in tenotomy of the hamstring muscles. If there be 
an injury to this branch, the anterior flexor muscles of the foot are injured, and foot- 
drop follows, the foot dragging when walking. If the sciatic nerve be divided or 
injured, all the leg muscles are paralyzed. The muscles of the thigh are not 
injured, and the patient can walk by throwing the leg from the hip forward. 
There is some impairment of sensation, but this is not as great as the loss of 
motion. There is loss of sensation in the foot and upper parts of the leg. 
Division and injury to the pneumoc/astric nerve are rare. A few instances have 
been reported, and in the removal of tumors of the neck the vagus has been 
injured in a few cases. Roswell Park has collected 50 cases of injuries to the 
pneumogastric during operations upon the neck, and finds that the statement in 
older writers that this is a fatal accident is not warranted by the facts. He also 
collected 15 cases of accidental injuries of the pneumogastric. The result in 2 is 
not known, but of the 13, 2 recovered. He concludes, therefore, that injuries to the 120 
SURGERY OF THE PERIPHERAL NERVOUS SYSTEM. 
pneumogastric are not, as has been said, immediately fatal. Wyeth suggests that 
if the pneumogastric or hypoglossal or other important nerves be divided, they 
may be sutured immediately, and Bloodgood is reported to have successfully 
sutured the pneumogastric. In most of the reported cases, according to Park, 
there were no symptoms directly following division of the vagus. 
Cases of injury of the phrenic, however, are followed by severe dyspnoea, 
which in some instances is fatal. 
Neuralgia. 
The subject of neuralgia belongs properly to a medical rather than 
a surgical treatise, and this is also true in regard to the medical treat- 
ment. In some instances, however, neuralgia is due to peripheral 
irritation, compression, or degeneration, rather than central or con- 
stitutional causes, and surgical interference is justifiable for the pur- 
pose. 
Neurotomy, neurectomy, nerve-stretching, have all been employed 
for obstinate neuralgia, especially for the violent form of trifacial 
neuralgia. 
Division of the nerve (neurotomy) for neuralgia, as well as nerve- 
stretching, does not give as satisfactory results as excision of a portion 
of the trunk—neurectomy. In some instances of trifacial neuralgia a 
permanent cure results, and temporary relief follows this procedure in 
all suitable cases. 
Recurrence of pain is not infrequent, however, in the most obstinate 
cases, and recourse has repeatedly been had to removal of the Gasserian 
and other ganglia for relief. 
Muscular Spasm. 
Operations upon the peripheral nerves are sometimes necessary for 
the relief of muscular spasm. The particular affection for which neur- 
otomy, nerve-stretching, or, better, neurectomy, has been most often 
attempted is that spasm of the muscles of the neck known as spasmodic 
torticollis. Successful cases have been reported by Gairdner, Keen, 
Richardson, and others, but in some instances the operation affords little 
or no relief. Keen has recommended a division of the posterior cervical 
nerves on the opposite side, in addition to resection of the spinal acces- 
sory on one side. This has been done by the operators mentioned, and 
with success in some instances. 
Operative interference should not be considered until after a thorough 
trial of all other measures. Of these, a complete rest of the muscles 
from the labor of supporting the head is of importance. Fixation of 
the head by a plaster bandage holding head and thorax, recumbency 
with light traction applied as in cervical caries, accompanied by massage 
and graduated muscular exercises, carefully prescribed and thoroughly 
carried out, present a rational form of treatment which is sometimes 
successful if persisted in for a long period. Mechanical appliances are 
of temporary assistance. A few instances have been reported by the 
use of conium, atropine, and gelsemium. In case of failure of all other 
measures, neurectomy of the spinal accessory, and, if necessary, of the 
posterior cervical nerves, gives some promise of success. OPERA TIONS UPON NERVES. 
121 
Operations upon Nerves. 
The operations upon nerves are nerve-suture, nerve-grafting, nerve- 
stretching, division of nerves, and excision of parts of nerve-trunks. 
Nerve-suture.—Nerves should be sutured as soon as they are 
divided, if that be feasible (primary suture), even if the nerve be only 
partially divided. Two or three sutures are passed, not only through 
the sheath of the nerve, but also, if necessary, through the nerve itself, 
avoiding twisting the nerve-fibres. Fine catgut or silk should be used 
and a round needle. Fixation of the limb on a splint is advisable after 
nerve-suture in order that the sewn nerve should not bo torn apart on 
motion. If there be separation of the ends of the nerves, they can be 
approximated by stretching, with fixation of the limb in such position 
as best to relax them. Suture can be also attempted weeks or months 
after the injury (secondary suture); the proximate end is ordinarily 
easily found from its bulbous termination, but the distal end is not 
so easily discovered. Recovery with restoration of function takes place 
in two-thirds of the cases operated upon. In 84 cases of primary 
suture reported by Howell and Huber, 42 per cent, were successful. In 
secondary suture the same writers report, in 80 cases, 38 per cent, of 
successes, 12 per cent, of failures, 50 per cent, with improvement. 
Nerve-grafting.—Experiments have been tried in grafting nerves 
where the gap between the ends from a loss of the nerve-substance is so 
extensive that the ends cannot be approximated even by stretching. 
Reported cases of success by this method have been reported when the 
sciatic nerve of a dog has been used. 
Nerve-stretching or Elongation.—A nerve can be stretched one- 
twentieth of its length. The amount of resistance to stretching is greater 
than would be imagined. 
The sciatic does not break under a strain of less than 80 pounds; 6 pounds’ 
pull is necessary to break the supraorbital nerve, according to Marshall. The 
amount of force required is greater in living than in dead subjects. The facial 
nerve will bear a strain of from 5 to 7 pounds, so that the head can almost be lifted 
from the table without a rupture of the nerve-trunk. 
The theory as to the benefit of nerve-stretching is that changes in 
nutrition follow, while adhesions to the neighboring parts or to the 
sheath are destroyed. Nerve-stretching is done by exposing the nerve and 
loosening it from the surrounding tissues: it is then stretched by hook- 
ing it under the thumb, or in some nerves, as the seventh, by a button- 
hook. Nerve-stretching by what has been called the bloodless method 
has been employed on the sciatic nerve. This consists in flexing the 
thigh forcibly upon the trunk, the leg being kept straight at the knee 
while the patient is under an anaesthetic. The method lacks surgical pre- 
cision, although some cases have been reported where benefit has fol- 
lowed. Nerve-stretching has been used in certain cases of spasm of the 
facial muscles and in wry neck, but the benefit of this procedure is usu- 
ally only temporary. 
Neuroplastic Surgery.—This has been advocated as a substitute for 
nerve-grafting. A portion of the severed nerve at each of the cut ends 
is split and freed nearly to the termination; these strips of nerve are 
folded over and their unattached ends stitched together. This method 
is as yet in an experimental stage. 122 
SURGERY OF THE PERIPHERAL NERVOUS SYSTEM. 
Operative Details. 
The operative details for the finding and resection of the different 
nerves require especial attention in each individual case. The few fol- 
lowing facts are to be borne in mind by the surgeon in considering ope- 
rations upon the nerves and nerve-structures most commonly attacked : 
The Supraorbital Nerve.—A curved incision, an inch in length, is made 
across the orbital notch, which can usually be felt. The incision can be made in 
the eyebrow and the scar will be hidden by the hair. 
The Division of the Fifth Nerve at the Superior Maxilla.—The infra- 
orbital nerve comes to the surface at the infraorbital foramen. This is found at the 
intersection of a line drawn from the superior orbital notch downward between 
the two lower bicuspid teeth. A curved incision one and a half inches long is 
made just below the lower border of the eye: where this incision meets the line 
already mentioned the nerve will be found. It lies under the levator labii supe- 
rioris. The nerve can be lifted from its bed by a hook and dissected as far back 
as the orbit. A pull upon the nerve will remove nearly the whole of it. 
The Removal of Meckel’s Ganglion.—This ganglion can be reached by 
Chavasse’s modification of Carnochan’s method. This consists of an incision below 
the eye, T-shaped, the cross portion reaching from one corner of the eye to the 
other, and the upright nearly to the mouth. The infraorbital nerve is found and 
tied with a piece of silk. The antrum is opened by means of a trephine or chisel: 
a trephine is applied to the posterior wall of the antrum; the nerve is 
then drawn down after being divided from the cheek, and will serve as a guide to 
the ganglion, being pulled into the spheno-maxillary fossa of the foramen rotun- 
dum. Horsley does not trephine the antrum, but lifts the floor of the orbit, 
including the periosteum, and opens the canal by means of a sharp-pointed 
bone-forceps, and follows the nerve to the foramen rotundum. Luecke resects 
the zygoma, turns the temporal muscles up, and makes an opening for the 
ganglion. 
Inferior Dental.—This nerve can be reached in several ways. An incision 
two inches long is made along the lower border of the jaw; the flap is pushed 
upward, the masseter muscle being separated from the jaw, and a trephine is 
applied one and a quarter inches above the angle of the jaw. The nerve is then 
exposed. 
Removal of the Gasserian Ganglion.—The removal of this ganglion has 
been done in cases where the ordinary neurectomy has not given relief. This 
ganglion is removed in the following manner: The eyelids are sewn together for 
three days in order to protect the eyeball; a curved incision is made half an inch 
below the external angular process of the orbit, along the zygoma, to its posterior 
end, then downward to the angle of the jaw, and finally along the lower border of 
the jaw as far as the facial artery. This flap is brought forward; the zygoma is 
first divided and turned downward with the attachments of the masseter muscles; 
the coronoid process is divided and brought upward with the attachment of the 
temporal muscle. The internal maxillary artery may be ligated and the external 
pterygoid separated from the sphenoid and the external pterygoid plate. A half- 
inch trephine is applied in front and slightly to the outside of the foramen ovale, 
with the edge of the trephine just touching the foramen ovale. There is usually 
considerable hemorrhage. A strong light is advisable. In the first instance the 
eye was destroyed, and had to be removed. In later cases, however, this has not 
been the result. Mr. Horsley, instead of attempting to remove the entire ganglion, 
which he says cannot be done without opening the cavernous sinus, trephines and 
removes the squamous portion of the temporal bone, opens the dura, ligates the 
middle meningeal, lifts up the brain, and exposes the roots of the nerve as they 
pass to the Gasserian ganglion. These lie in a canal a quarter of an inch in diam- 
eter beneath the tentorium, which should be opened. The nerve-roots are cut and 
drawn away from the pons. This operation has never been done but once, and 
then with a fatal result. Mixter has resected the second and third divisions at 
both the foramen rotundum and ovale, and has done the operation successfully 
several times. He makes an incision similar to that for removal of the Gasserian 
ganglion. The temporal and pterygoid muscles are separated and turned down, 
using an incision which has been described by Salzer. OPERATIVE DETAILS. 
123 
Park has advised a preliminary ligation of the common carotid as a great help, 
no matter which method of attack be selected. 
Lingual Nerve.—This has been operated on to diminish pain in cancer of 
the tongue. The nerve lies on the floor of the mouth beneath the mucous mem- 
brane, and can be felt if the tongue be forcibly stretched. The mucous membrane 
is incised and a hook is passed under the nerve. The nerve can also be found as 
it lies in the tongue close to the first molar of the lower jaw. 
Fig. 51. 
Exposure of Meckel’s or the Gasserian ganglion (Krause). 
Fragment removed from the fifth nerve. 
The Seventh Nerve.—This nerve is reached by a vertical incision two and 
a half inches long made behind the ear: the parotid is found at its posterior limit 
and is turned forward; the sterno-cleido insertion is then found, and in the space 
between these two landmarks the prevertical muscles will be found. The inferior 
branch lies in front of the fasciae covering these muscles, and crosses both the 
mastoid and the vertical ramus of the jaw. This nerve can also be found by an 
incision in front of the ear: one of the main branches is found in the parotid 
gland, and is followed back until the main trunk is reached. 
Spinal Accessory Nerve.—This nerve is divided and excised for spasmodic 124 
SURGERY OF THE PERIPHERAL NERVOUS SYSTEM. 
wry neck. It may be reached anterior to the sterno-cleido-mastoid, an incision 
being made along the anterior body of the muscle, passing two inches downward 
from the lobe of the ear. The muscle is turned to the outside, and the nerve can 
be found a little above the level of the hyoid bone. If it be desired to reach the 
nerve, as it is possible, from the sterno-cleido-mastoid, the incision is made along 
the outer border of the muscle, the centre of the incision being the centre of the 
muscle. The nerve will be found a little above this point. 
Division of the Nerves in the Deep Posterior Cervical Plexus.—Keen 
divides the posterior branches of the first, second, and third cervical nerves in 
spasmodic torticollis which has been unrelieved by the incision of the spinal 
accessory. A transverse incision is made half an inch below the level of the lobule 
of the ear. The trapezius muscle is divided in the same line. The muscle is then 
dissected up and the great occipital nerve is found. The complexus is then divided, 
and the great occipital nerve is followed until its origin from the posterior division 
is reached. The suboccipital or first cervical nerve is excised. It lies in the tri- 
angle close to the occiput formed by the two oblique muscles and the posterior 
straight muscle. The exterior branch of the posterior division of the cervical 
nerve is found lower down, and should be divided close to the bifurcation of the 
main nerve. 
The anterior branches of the cervical plexus may be reached by means of an 
incision along the posterior border of the sterno-cleido-mastoid muscle. 
The Brachial Plexus.j—An incision is made above the clavicle similar to 
that which is used for the ligation of the subclavian artery. The deep fascia is 
opened and the nerves will be found. 
Median Nerve.—The same incision is used as for the ligature of the brachial 
artery. The nerve lies in front of the artery and passes from within outward. The 
median nerve can be reached in the forearm or the wrist. An incision two inches 
long is made on the inner side of the tendon of the palmaris longus. The nerve 
lies underneath the deep fasciae. The branches of the median nerve to the thumb 
and fingers can be reached by an incision along the lower inferior border of the 
thenar eminence underneath the palmar fascia. 
Ulnar Nerve.—An incision is made similar to that for the finding of the 
median nerve. The nerve lies farther back. It can be exposed behind the elbow, 
using an incision between the internal condyle and the olecranon. At the wrist an 
incision on the radial side of the tendon of the carpi ulnaris exposes the nerve, 
which lies under the deep fasciae. 
The Musculo-spiral Nerve.—An incision is made between the biceps and 
the triceps muscles. The deep fascia is opened, and the nerve is found in a groove 
in the interspace between the two heads of the triceps. 
The Radial Nerve.—A longitudinal incision is made on the outer border of 
the forearm three inches above the wrist-joint. 
The Great Sciatic Nerve.—An incision is made, four inches long, in the 
middle line of the thigh, beginning below the gluteo-femoral crease. The deep 
fascia is cut, the biceps is found, and the sciatic nerve will be seen at the outer 
border of the muscle. 
Tibial Nerves.—The anterior and posterior tibial nerves are found through 
the same incisions that are required for ligation of the arteries. 
Intraspinal Division of the Posterior Nerve-roots.—This ope- 
ration has been done by Abbe in a case of inveterate neuralgia. Half 
of the arch of the fourth and the whole of the fifth, sixth, and seventh 
cervical arches were removed by Abbe in his first case. The dura was 
exposed, and the sixth and seventh cervical nerves were divided between 
the dura and the bone. Temporary relief followed. The operation has 
also been done by Horsley and others. It is more serious than opera- 
tions on the peripheral nerves, and the results do not seem to be any 
more favorable. 
Nerve-tissue maybe involved in malignant growths developed in the 
surrounding tissues, but primary malignant tumors of the nerves are rare : 
Tumors op the Nerves. TUMORS AND DISLOCATIONS OF THE NERVES. 
125 
they are sarcomata or gliomata. (Vide Vol. I. Chapter XXVI.) The 
term neuromata, a general one applied to enlargements observed in 
nerves, is unfortunate. The most common form of* the neuroma is seen, 
after amputation, in the bulbous enlargements of nerve-ends which are 
involved in the surrounding tissue, though this can be more or less 
readily differentiated. A tumor may occasionally appear in the course 
of a nerve without apparent external irritation. This is due to an 
increase of the connective tissue which arises from the endoneurium, 
though sometimes from the perineurium, the axis-cylinder being there 
surrounded or its fibres pressed upon by the growth. These, are in fact, 
fibromata of the nerves. They are usually multiple and limited to cer- 
tain nerve-tracts. Sometimes these tumors are sessile, and sometimes 
they have a pedicle. They may be found in the nerves of the skin, and 
are sometimes called fibromata of the skin. In very rare instances they 
may attain considerable size, even being reported as large as the fist. 
Plexiform neuromata consist of a thickened mass of nerve-fibres resem- 
bling somewhat a plexus of veins. The nerve-fibres are elongated and 
tortuous and increased in numbers. These form true neuromata, and may 
be found in the head or in any part of the body. 
Dislocation of the Nerves. 
Dislocation of nerves has been reported in a few instances. This 
is easily recognized by a movable cord which is felt under the skin, and 
by a sensation which the patient notices when this is pressed upon. 
Where no other means alfords relief it is possible to cut down upon the 
the nerve and excise a portion, if it be not possible by section and suture 
to restore it to its place. Dislocation is most common in connection with 
the ulnar nerve at its passage back of the inner condyle. CHAPTER III. 
SURGICAL DISEASES AND INJURIES OF THE HEART AND 
PERICARDIUM, WITH SURGERY OF THE LARGE BLOOD- 
VESSELS; LIGATIONS. 
Duncan Eve, M. D. 
Malformations of the heart are, fortunately, of rare occurrence, 
for the most part represent survivals of foetal conditions, and pertain 
more to the domain of teratology than surgery, except as curiosities. 
Absence of the pericardium, still more rare, is mostly associated with 
misplacement of the heart, and must not be confused with adhesion of 
the pericardium and consequent obliteration of the sac, which is so fre- 
quent in after-life. The acardiac foetus can profit nothing at the hands 
of the most skilful surgeon; the defective arrangement of the valves 
and openings of the heart, limited entirely to a perpetuation of the con- 
ditions of foetal life, is solely within the domain of pediatrics; and 
thoracic fissures (fissura sterni) resolve themselves into those in which, 
besides the sternum, the skin is also separated, in which case the heart 
is exposed (cardiac prolapse), and those in which the integument is not 
cleft, and when the heart is covered by it (cardiac hernia) are left to the 
ingenuity and originality of plastic surgery, which alone can determine 
the best mode of procedure. 
Misplacement of the heart (situs mutatus) is also of rare occurrence con- 
genitally, and the more important cases are merely a part of a general 
malformation of the body. The heart may be transposed, occupying a 
position on the right side of the chest; with this there is usually a trans- 
position of other viscera, though it sometimes occurs alone. Or it may 
occupy the middle line, retaining permanently its position in early foetal 
life. Misplacements from pathological conditions of other viscera and 
structures are more frequent. Thus the heart may be pushed down lower 
than normal by aneurisms of the aortic arch or the large vessels at the 
root of the neck or morbid growths occupying the upper mediastinum; 
it may be pushed too far to the left or right by pleuritic effusions or col- 
lapse of one or other lung; or it may be pushed too high up by abdom- 
inal growths or adjacent visceral hypertrophy, fluid accumulations, or 
gaseous development, the latter producing the greatest degree of dis- 
placement. These are all to be watched for by the surgeon in operations 
on the heart or adjacent structures, and with an ordinary knowledge of 
percussion and auscultation are readily detected, needing only bare men- 
tion here by way of precaution. The history of the case and a careful 
examination of the heart itself and adjacent structures generally suffice 
for a solution of the existing condition and its cause. 
126 WOUNDS AND INJURIES OF THE HEART AND PERICARDIUM. 
127 
Wounds and injuries of the heart and pericardium have been, 
and are likely to be, of only too frequent occurrence. The well-known 
site of the heart has made it only too accessible to the death-dealing 
instrument of the suicide or assassin ; its feebly protective surroundings, 
especially in front, leave it only too approachable to sword-thrust, bayonet, 
or bullet on the battle-field, or missiles and fragments projected by inten- 
tional or unavoidable and accidental force. Most generally, the excep- 
tions being few and far between, lesions of any magnitude—and some 
quite slight ones, indeed—have and will prove fatal. Yet the history 
of the past has shown quite a number of slight and some severe wounds 
that have not been immediately lethal, and yet a few where life was pro- 
longed indefinitely or determined by some altogether different cause. 
The number of favorable results in such lesions have been largely added 
to in the last thirty years, and it is to be hoped will yet be still more 
largely increased. 
In “ A Collection of Remarkable Cases in Surgery,”1 made by my father, the 
late Prof. Paul F. Eve, M. D., nearly forty years ago, he collated from various 
authentic sources twenty cases of wounds of the heart, produced by various instru- 
ments and missiles ranging all the way from the musket-ball to a large sewing- 
needle, which may be briefly summarized as follows: 
1. Mr. Lees (Dublin Journ. Med. Sciences, 1837). A pistol loaded only with 
powder, placed directly against the chest at apex of the heart; great depression, 
anxiety, sense of weight about the heart, tendency to fainting and severe palpita- 
tion, with recovery in a few days. 
2. E. R. Maxson (in Buffalo Med. Journ., 1831). Rupture of right auricle 
from lifting heavy weight; walked about the house the two following days ; 
slight symptoms of dizziness at close of second day; on retiring to rest became 
thirsty, called for drink, and immediately died. Autopsy showed the rupture 
large enough to admit a crow-quill, and pericardium distended with coagulated 
blood. 
3. J. H. McNicoll (in Lancet, 1852). Rupture of heart on getting up too soon 
after delivery; death in a short time—about half an hour. 
4. Case of Due de Berri. Opening of ventricle by dagger; Dupuytren in attend- 
ance, who kept the wound open ; patient lived several hours. 
5. Charles E. Lavender, M. D., report to Med. Ass’n of Alabama. Right ven- 
tricle penetrated by blade of knife; complete recovery—a most remarkable case, in 
which the rest treatment was faithfully carried out (1850), 
6. Mr. Lees (Dublin Journ. Med. Sciences). End of sword passing through right 
auricle; death on second day. 
7. Ibid. Wound of heart by fractured rib ; death after some hours. 
8. Ibid. Heart transfixed by iron stilet; patient lived twenty hours. 
9. J. L. O’Connor, M. D. (London Med. Gazette, 1821). The heart transfixed 
by a darning-needle in an attempt at suicide; recovery. 
10. Dr. Renauldin and M. Boujet (in Patterson’s Med. Register). Death from 
pericarditis due to a needle introduced (suicidal) into the heart five days previ- 
ously. 
11. M. Trelat (Bull. g&n. Th'er., 1846). A large needle removed from the heart 
after three days’ sojourn in it without ill consequences; needle two inches long, 
and oxidized when removed. 
12. J. McNeill, M. D. (Med. Exam., 1849). Needle found in the heart upon 
dissection; had evidently been there more than a year. 
13. Thomas Dorris, M. D. (Am. Journ. Med. Sciences, 1834). Lacerated wound 
of the heart by a fragment of wood; healing of wound; death on thirty-seventh 
day. 
14. Lancet, 1846. A very important case reported by Mr. Holmes, in which the 
anterior wall of right ventricle was opened by a linear wound (gunshot) without 
perforation of pericardium; death soon after. 
1 Eve’s Surgical Cases, 8vo, p. 858, 1857, J. B. Lippincott & Co. 128 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
15. L. Randall, M. D. (Am. Journ. Med. Sciences, 1829). Death sixty-seven 
days after gunshot wound from fowling-piece, three small shot found in right ven- 
tricle and two in right auricle. 
16. Dr. A. Christison (in Edin. Monthly Journ. and Rankin’s Abstract, 1853). 
A gunshot wound one inch outside of left coracoid process, passing downward into 
the thorax, received April 14th; death at the end of June following, and musket- 
ball found in left ventricle at apex, partly covered by a layer of white lymph. 
17. Schmidt’s Jarbuch. and Br. and Foreign Med.-Chir. Rev., 1852. A ball found 
in right ventricle, having dropped down into it through pulmonary artery; death 
twenty minutes after reception of wound. 
18. Dr. Latour. A soldier shot in the chest; great hemorrhage, which grad- 
ually subsided; wound cicatrized at end of three months, after which no incon- 
venience other than palpitations for three years; death six years after reception 
of wound, not due to palpitations; the ball was found in the right ventricle near 
its point, lying on the septum medium. 
19. Dr. Finnell, N. J. {Med. Reporter, June, 1855). The prize-fighter Poole in 
a pugilistic encounter with Baker was shot with a revolver, and so far recovered 
that he wanted to renew his encounter on the fourth day afterward. Death twelve 
days later; ball found lodged in the septum between the ventricles, about one and 
a half inches from the apex of heart, and one-fourth of an inch from its surface. 
20. Dr. M. Marini {J\ded. Examiner, 1844). The left ventricle opened by a 
dagger; death nine weeks afterward. 
In addition eight other cases are cited in which the cavities of the heart were 
penetrated by bullet, 1; stab with sharp instrument, 3; heart transfixed entirely, 1 ; 
needle, 1; piece of ramrod, 1; bayonet, 1—the individuals dying at different inter- 
vals varying from nine hours to sixty-six days. 
Since this “ Collection ” was made quite a number of cases have been reported 
by various observers in which life has been prolonged from a few hours to days, 
weeks, months, and even years. Fischer collected 452 cases of heart-wounds in 
which death occurred in two or three minutes after the injury in about one-fifth of 
the cases, and 72 recovered; the diagnosis in 88 verified by subsequent post-mor- 
tem, death being from other causes. 
Wounds and injuries of the heart produce deatli by—1, hemor- 
rhage ; 2, shock ; 3, arrest of the heart’s action by the accumulation of 
blood in the pericardium or around the heart in the thoracic cavity; 4, 
by inflammation, suppuration, or sequelae due to the subsequent progress 
of the wound, lesions set up thereby, or induced by the character of the 
injury and the instrument producing it. The danger is greater and more 
imminent by reason of the character of instrument producing the wound, 
and stands in the following order: (o) contused and lacerated wounds, 
such as gunshot wounds, those produced by blunt and irregular instru- 
ments, etc., and punctured wounds if the instrument is of large si/e; 
(b) incised wounds; (c) punctured wounds made by small instruments. 
In most instances the hemorrhage in contused and lacerated wounds will 
be so severe as to cause death almost immediately; and shock, exces- 
sive inflammatory, suppurative, and other sequelae are more certain to 
supervene. Incised'wounds are not always attended by immediate alarm- 
ing or serious hemorrhage, and shock may be at first slight. A thin, 
narrow blade transfixing the muscular walls makes a valve-like opening 
by means of the interlacing muscular fibres; severing some, it passes 
between others; while shock is also apt to be slight. A greater danger 
is from the accumulation of the blood around the heart, impeding or 
arresting its action. Punctured wounds are likely to be attended with 
shock, hemorrhage, and subsequent developments in proportion to the 
si/e of the agents by which they are produced. 
The evidence of wounds of the heart may be summarized as follows : 
character, site, course, and nature of instrument producing the wound, WOUNDS AND INJURIES OF THE HEART. 
129 
together with certain phenomena referred to the heart itself, as a systolic 
bellows-sound, a peculiar tremor about the heart, with small, intermit- 
tent pulse, an undulating crepitation and bruit, and such phenomena as 
can be obtained by careful auscultation and percussion. Dulness upon 
percussion over an increased and increasing area, syncope, precordial 
anxiety and dyspnoea, diminished impulse of the heart, and pain may 
be suggestive when present. 
Treatment.—The patient should at once be placed in the recumbent 
position and kept there, with head low and every possible movement 
prevented. If he has to be moved, it must be done with the greatest 
care and caution to prevent any undue movement of the body, and 
should be preceded by a full dose of morphia hypodermically. Nar- 
cosis as deep as may be considered safe should be maintained for some 
days—at least until all danger from shock and hemorrhage is considered 
past. Thirst should be prevented so far as possible, and nutrition 
maintained rather by copious enemata of fluids and semi-fluids than by 
the mouth, the act of deglutition, even of fluids, having the elfeet of 
increasing the heart’s action, which is to be avoided as adding to the 
danger from hemorrhage. Digitalis should not be given, nor stimulants; 
far better will be found veratrum and other cardiac sedatives: to dimin- 
ish as much as possible the heart’s action is of the greatest importance. 
So long as the heart’s action seems to be maintained to a reasonable 
degree, only the simplest antiseptic dressings to the external wound 
are called for. A flannel bandage applied as tightly as consistent with 
comfortable respiratory movement should be early applied and main- 
tained in position. Over this an ice-bag or cold applications, rapidly 
evaporating lotions if the ice-bag seems to disturb the patient by its 
weight, or cold cloths frequently reapplied. The strictest quiet of sur- 
roundings and of the patient’s mental condition is imperative. 
If life be maintained for twelve to twenty hours or more, and a care- 
ful examination, which should be made at frequent intervals without 
disturbing the patient, shows that the heart’s action is becoming impeded 
by the pressure of extravasated blood around it, manifested by more 
feeble pulse and heart-sounds, cyanosis, dyspnoea, etc., then comes the 
propriety of opening the chest and pericardium, removing clots and 
blood by washing out with warm water thoroughly sterilized or other 
means. This may be done by simple incision between the fourth and 
fifth ribs on the left side, if other location is not indicated by the cha- 
racter of the wound, or by excising the cartilages of one or more ribs. 
An incision a few lines within the border of the sternum parallel with 
the lower border of the fifth rib or lower, extending outwardly about one 
and a half or two inches or more, is made; then a similar one parallel 
with the upper border of the fourth or third rib, or higher if deemed 
necessary, connecting the two by a transverse incision about the centre 
and turning the flaps well back. The costal cartilages, having been 
separated from the sternum, may be elevated, and the ribs or their car- 
tilages severed at a point distant enough from the sternum to give 
sufficient room. The internal mammary artery may have to be secured, 
as well as the intercostals. Pushing the pleura to one side (if this has 
not been done by the distended pericardium), the pericardium can be 
opened to such an extent transversely or longitudinally as may be 130 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
deemed advisable. Gussenbauer performed this operation satisfactorily 
for purulent pericarditis after the above method. The site chosen is the 
one of election. 
The following is a brief synopsis of a case reported by H. C. Dalton, 
M. D., of St. Louis in 1894 : “ A man in a fight was stabbed over the 
left breast; the wound was an inch in length and an inch and a half above 
the left nipple. There was little hemorrhage from the wound, and 
normal cardiac dulness was found on percussion. The percussion of the 
chest showed absence of dulness. The wound was closed and antiseptic 
dressings applied. Ten hours after admission to the hospital percussion 
revealed dulness over the entire left side, and much pain was com- 
plained of. The patient was removed to the operating theatre and the 
dressings taken off, when it was found that blood and air gushed from 
the wound with each inspiration. An incision was accordingly made, 
eight inches in length, over and parallel to the fourth rib, and six 
inches of the rib resected. The intercostal artery having been tied, the 
pleural cavity was found full of clotted and fluid blood, which with 
each inspiration poured from the wound with great force. The patient 
was turned on his left side, and with a long pair of forceps, armed with 
a sponge, the pleural cavity was cleansed of blood. Subsequently it 
was discovered that a transverse wound of the pericardium existed to 
the extent of two inches, and steps were taken to suture the lesion. In 
carrying out this procedure great difficulty was experienced, owing to 
the pulsation—at the rate of 140 per minute—of the heart. The peri- 
cardium with each pulsation of the heart rose and fell, and, in order to 
carry into effect that which was being attempted, it was necessary to 
follow the movements of the organ. Ultimately, a continuous suture 
of catgut was satisfactorily inserted in the wounded pericardium; the 
pleural cavity was then thoroughly irrigated with sterilized warm water, 
the external wound closed, without a drainage-tube, and antiseptic 
dressing applied. It may be noted that at several stages of the opera- 
tion, which lasted an hour, the patient seemed to be dying, and in order 
to avert collapse hypodermic injections of whiskey and strychnia were 
resorted to. Before the pericardial wound was sutured, examination of 
the heart was made with a view to the discovery of a wound in the 
organ, but no lesion was found. The patient made an uninterrupted 
recovery.” 
Thirteen years ago Dr. Block of Strasburg pointed out that death 
in cases of heart-wounds resulted, as a rule, from hemorrhage, not shock, 
and that sufficient time was often given for suture, which his experi- 
ments on dogs showed was possible. De Vecchio made a similar report 
at the last International Medical Congress at Rome, 1895. 
These are the general outlines suggested; it may be necessary to 
vary them in any particular case: First, regard the most imminent 
danger and ward it off—by passive measures if possible, and, if they 
seem to be ineffectual, resort to active ones, always keeping within the 
lines of reason and a correct knowledge of the situation. 
Should it become necessary, as I believe it to be possible, to suture 
a wound in the heart-walls, interrupted sutures closely applied, made 
of thoroughly aseptic animal tissue, should be used; so also in closing 
the wound in the pericardium. While aseptic silk will be encysted, PARACENTESIS OF THE PERICARDIUM. 
131 
here we want absorption of the suture, which will not be necessary to 
remain very long: forty-eight hours will amply suffice for adhesion in 
so vascular an area. Park has shown the success of this measure in 
dogs. 
Paracentesis of the heart, or cardicentesis, may be neces- 
sary in cases of engorgement of the right cavities from pulmonary 
disease where death from dyspnoea is imminent from the overtaxed con- 
dition of the heart. While it should never be resorted to so long as 
other measures hold out any hope, death should at least be held at bay 
as long as possible by resort to this operation, and a successful issue 
may result. It is a well-attested fact that the introduction of a small, 
aseptic aspirator or other needle into and through the heart-walls has 
produced no material injury of this organ. 
Of the two cavities of the right heart, I would prefer the ventricle, 
by reason of its thicker walls. Introducing the needle into the space 
just above the fourth rib, about one inch to the right of the sternum, 
and pushing it backward, inward, and slightly downward, or going in 
just above the fifth rib and pushing it directly backward and inward, 
the right ventricle may be reached—the only precautions being that the 
aspirator be in good working order and the needle thoroughly aseptic, 
as should be the site of puncture as well as the operator’s hands. From 
three to six or more ounces of blood may be withdrawn as the exigen- 
cies of the case may require. Dr. G. C. Cottam of Pock Rapids, Iowa, 
has reported a case in which he, in his efforts to reach the right auricle 
through the sixth interspace, tapped the left ventricle: the result was, 
however, satisfactory, as his patient, who was in an advanced stage of 
incipient phthisis and at the point of death, lived six weeks longer, and 
was far more comfortable, death being due to exhaustion. 
Dr. Allan D. Sloan has reported a case in which he plunged a trocar attached 
to an aspirator directly into the right side of the heart, through which some 
eight ounces of blood flowed. This happened in the case of a woman suffer- 
ing from pericarditis with effusion. The woman was apparently dead from heart 
failure, its action having ceased, and a hurried attempt was made to evacuate the 
fluid with the above result. He supposed when the blood flowed that the woman 
would die from the heart injuries. However, the cannula was withdrawn a little, 
the fluid evacuated, and, to the doctor’s surprise, the heart began to beat again, 
and after an hour or two the patient regained consciousness; two months later she 
was sent to the country, and four months later was reported as being perfectly 
well. Park has even tapped an abscess in the heart-wall. 
Numerous other cases might be cited from the literature of the past, but these, 
the most recent, are deemed sufficient. 
Paracentesis of the pericardium is now a well-known pro- 
cedure, though not so frequently resorted to as it should be, notwith- 
standing the valuable addition to its literature made by Prof. John B. 
Roberts, M. I)., of Philadelphia, in his most excellent monograph. 
Paracentesis should unhesitatingly be resorted to whenever life is in 
danger from distention of the sac by an effusion of any extent, no 
matter what the amount of the effusion or the cause of the disease 
may be. Roberts says : “ Whenever the effusion, whether it be serum, 
pus, or blood, accumulates so rapidly or in such quantity that it threat- 
ens to destroy life and refuses to undergo absorption by ordinary treat- 
ment, it is the duty of the attendant to tap the distended sac.” Given 
an excess of fluid in the pericardium, great or small, and a manifesta- 132 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
tion of failure of the vital powers not due to other well-defined causes, 
indicated by feeble cardiac action, ill-defined and weak heart-sounds, 
thready and flickering pulse, cyanosis, dyspnoea, orthopnoea, etc., then we 
do not hesitate to use the aspirator any longer than to take timely and 
necessary precautions that have already been suggested in tapping the 
heart—viz. a good working instrument, small needle, and strict asepsis. 
The point to be selected is preferably in the fourth or fifth left inter- 
costal space, about two to two and a quarter inches to the left of the 
median line of the sternum, entering rather nearer to the upper edge of 
the lower rib bounding the space, pressing the needle backward and 
slightly inward until the sense of resistance is no longer felt by reason 
of the needle entering the sac or the fluid appears in the outflow tube. 
The patient should be as nearly recumbent as possible, to allow the heart 
to fall back from the anterior wall of the sac. Should the sac refill, it 
can be again emptied, and in the event that pus, and not serum, in a first 
or subsequent aspiration appears in the outflow, there is nothing to be 
done when the sac fills again, as it surely will, but open incision1 and 
thorough drainage, as in a case of empyema of the pleura. Care should 
be taken in the introduction of the needle, and a just estimate made as 
to the depth at which the heart will be found: this reached and no evi- 
dence of having gained access to the sac existing, the needle had better 
be withdrawn slightly and pushed forward in a little different direction 
again, or another site tried. If the cartilage is perforated, a disk may 
Fig. 52. 
block the lumen of the needle and cause error; this will not occur, 
however, if the H. Landis Getz trocar and cannula be used, which are 
by far the best if those small enough can be secured, as after the trocar 
is withdra\ u a rounded and not a sharp point is left to come in contact 
with the heart-wall as the effusion escapes. The Fitch dome trocar, if 
of small size, is also a very suitable instrument, as is the one suggested 
by Roberts. 
If, after the second or third evacuation of a serous exudation, the sac 
again till, the injection into the sac of a solution of iodine (tr. iodini, 
3 fluid drachms; potas. iodidi, 20 grains; aq. dest., 10 fluid drachms) 
has been proven to be both applicable and successful. 
Quite a number of able authorities have advised other points than 
the one suggested, which is the one preferred by Roberts, and which I 
deem the most suitable, except in cases in which a bulging of an inter- 
costal space or at some other point may indicate that the fluid can be 
more easily reached. 
Roteh of Harvard University advises the fifth right interspace as 
being the most accessible, and with less danger of puncturing the over- 
Small trocar and cannula—can be used with or without aspirator. 
1 First practised by Romero in 1801, afterward by Rosenstein and others. LIGATION OF ARTERIES. 
133 
lying pleura than the left side. His observations possibly having been 
made on children, the heart is more likely to be found nearer the central 
line than in adults. Professor O. H. Wilson, M. I)., of Vanderbilt Uni- 
versity, however, has reported a successful case of tapping in the posi- 
tion recommended by Ilotch in an adult. Ebstein of Gottingen also 
reports a similar case. 
In purulent pericarditis, which cannot be definitely diagnosed until 
the character of the fluid is open to ocular inspection, there is only one 
course of procedure. It has been thought that a purulent effusion would 
be indicated by a greater degree of severity in the clinical phenomena, 
greater depression, a lower state of health, more feeble cardiac and pulse 
movement, etc. But there is no satisfactory and reliable evidence other 
than the fluid itself: this may be obtained by a long needle attached to 
an ordinary hypodermic syringe. When we are satisfied that there is 
pus within the pericardium, it should be thoroughly evacuated by a free 
incision, a drainage-tube inserted, and, if thought necessary, the cavity 
washed out with a warm (100° to 105° F.) mild antiseptic solution. Or 
it may be well enough, in order to secure thorough drainage, to remove 
a section of one or more ribs, which will be advisable in some cases. 
A case reported recently by Eiselberg in Wiener Min. Wocli. is of special 
importance, it being that of a boy of seventeen who developed purulent pericar- 
ditis after a stab wound of the pericardium. Puncture of the pericardium having 
been performed several times without relief, incision was determined on. The 
cartilage of the fourth rib on the left was resected, and the thickened pericardium 
exposed. After exploratory puncture it was opened by a transverse incision 4 cm. 
in length, and 2 litres of sero-purulent fluid were evacuated. The cavity was 
washed out with warm water, salicylated, the borders of the pericardial incision 
stitched to those of the wound, and two drainage-tubes inserted. Complete 
recovery took place in four weeks. Eiselsberg insists upon the importance of 
suturing the pericardium to the lips of the wound to prevent infection of the 
pleura. 
In cases of hydropericardium due to renal disease or other cause than 
pericarditis I would prefer an open incision and drainage rather than 
repeated tapping. 
Ligation of Arteries. 
The ligation of arteries is resorted to for the control of hemorrhage, 
the cure of aneurisms, the arrest of the growth of inoperable tumors, 
and the relief of hospital gangrene. While the necessities of the ease 
may require any point to be selected, the operations here given are at 
the site of election, and may have to be materially modified to meet the 
exigencies of the occasion. The essentials are a correct knowledge of 
the anatomy of the part and the principles of modern or aseptic surgery. 
It is not essential in all cases, as was taught by Celsus and others in 
his day, to use two ligatures, dividing the vessel between them, one 
ligature usually sufficing, leaving the artery undivided, as in the event 
of secondary hemorrhage at the site of the operation the vessel will 
again be more readily found. Nor is it necessary in using the aseptic 
ligature to tie the artery so tight as to divide the internal and middle 
coats, but only to press the opposing surfaces together temporarily to 
secure obliteration of its canal. The intima becomes covered with 134 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
granulations, developed from it and the clot that forms at the point of 
arrest of the circulation, which, uniting, form a firm union ; also plastic 
matter forms around the ligature, absorbing it if of animal tissue or 
encysting it if of aseptic silk, the exudate strengthening the vessel 
at the point of ligation. If an artery be divided and its extremity 
is to be secured, the knot should be sufficiently tight to prevent its slip- 
ping off. 
The ligature should be of perfectly aseptic silk, proportionate in size 
to the vessel to be secured, which I prefer to silkworm gut, catgut, or 
other animal membrane. Silk can be thoroughly sterilized by boiling, 
and is much safer and more reliable. 
The instruments necessary are a scalpel, two pairs of dissect! ng-for- 
ceps, wound-hooks, retractors, rat-toothed forceps, pressure-forceps, 
aneurism-needles, ligatures, and aseptic absorbent cotton to use for 
sponging; a head-mirror will be found useful for illuminating a deep 
incision. In securing the deeper-seated arteries, as the iliacs, broad 
metal spatulse and large rectangular retractors will be of use. 
The position of the patient will vary a little according to the artery 
to be secured. In general, the surgeon should stand on the side to be 
operated on, making the incision from above downward on the right and 
from below upward on the left side. 
The line of the artery must be well located, which may vary from 
what is usually given as the anatomical line of the vessel, and a special 
position of the part is essential, varying with the portion of the artery 
and the vessel to be secured ; also, the operator should be well aware of 
possible anomalies of position, congenital or the result of previous 
wounds and operations. 
The scalpel should be held in what is known as the dinner-knife 
position, and a clean, free incision made through the integument over 
the of the vessel, the knife entering at right angles to the surface, 
retaining this position when withdrawn, so that the wound should be of 
equal depth throughout. The length of the incision will depend entirely 
on the vessel to be secured, but had better be several lines too long than 
one line too short, so that free access to the vessel can be had. The 
skin should be steadied with the fingers of the left hand while it is 
divided. The superficial fascia, having been divided, brings us to the 
deej) fascia, beneath which the underlying muscles and tendons are more 
or less distinct. The separation between two muscles has usually to be 
followed, and in ordinary fleshy cases will be indicated by a white or 
yellowish line, but this is not so apparent in emaciated persons. The 
deep fascia having been divided with the finger-nail or the handle of 
the scalpel—its cutting edge should not be used here—we endeavor to 
work down between the muscles until the artery is reached, the pul- 
sations generally being a sufficient guide to the educated finger. If the 
limb was extended when the first incisions were made, it may now be 
slightly flexed, so as to relax the muscles and afford easier access to the 
artery. 
With retractors in the hands of an intelligent assistant, firmly held, 
and careful sponging of the wound with aseptic gauze or cotton, all 
bleeding branches either having been secured by ligature, torsion, or 
temporarily by catch-forceps, the sheath of the vessel is brought into LIGATION OF ARTERIES. 
135 
view. Superficial veins that may be made apparent by pressure and 
nerve-trunks or branches must be carefully avoided or pushed to one 
side. 
The artery when reached will be apparent to the sense of touch. 
When held between the finger and thumb it can be compressed and its 
pulsations will be apparent; it is less easily compressed than a vein, 
which swells out below on pressure, and scarcely feels like a tube, while 
the nerve cannot be flattened by pressure, and is firm, resisting, round, 
and cord-like. If an aneurism exists beyond the site of operation, pul- 
sation in it will cease on compressing the artery. 
It next remains to open the sheath and clear a part of the vessel for 
the passage of the aneurism-needle. The sheath is picked up with a 
pair of rat-toothed forceps, grasping it in a transverse position or at 
right angles to the course of the vessel, held firmly and well up from 
the artery, and a clean incision from one-quarter to one-half an inch 
made in it parallel with the direction of the artery; the blade of the 
scalpel should be inclined obliquely, with the flat of the knife toward 
the artery. 
Retaining hold on the sheath by means of the forceps in the left 
hand, the scalpel is exchanged for the aneurism-needle, which should be 
gently insinuated halfway around the artery within the sheath, enter- 
ing on the side of the incision held by the forceps, which are now 
detached, and the sheath on the other side of the incision is grasped and 
held up; moving the point of the needle slightly from side to side, it is 
gently insinuated entirely around the vessel until the eye emerges from 
the opening in the sheath. The ligature is then inserted in the eye of 
the needle, which is withdrawn, bringing the ligature with it. Care 
must be taken not to include a vein in the ligature, and more especially 
the trunk of a nerve, which can be ascertained by making careful trac- 
tion on both ends, slightly lifting the artery. 
The needle should be kept throughout at right angles to the artery, 
and should never be threaded until it has passed around the vessel. The 
ligature should be passed and tied also at right angles to the artery with 
a “ reef-knot,” unless there are special indications for the use of the 
“ surgeon’s knot.” 
The points of the two fore fingers, with the ends of the ligature 
in the hand passing over them, should meet upon the artery as the 
knot is being tightened, and care should be taken that the artery is not 
dragged out of its place. The knot should be tied gently, slowly, and 
firmly, avoiding anything like a jerk. 
The wound is closed by superficial and deep sutures if the latter are 
considered necessary, well dusted with iodoform, and the limb bandaged. 
If the main artery of a limb is ligated, it shoqjd be slightly elevated, 
kept sufficiently warm by artificial heat, bottles of hot water, etc. if 
necessary, and absolute rest maintained for two or three weeks longer— 
in case of the subclavian, iliac, or common femoral absolute rest is 
imperative for at least three weeks. 
Ligature of the Innominate Artery.—The patient lies upon the back 
close to the edge of the table, chest raised, and head extended and turned 
to the left, with the arm pulled down and securely fixed. The surgeon 
stands on the right side and in front of the shoulder. A good light is 136 
SURGICAL DISEASES AND INJURIES OF TIIE HEART. 
essential, and means should be at hand for getting it well down into the 
depths of the wound. 
Along the upper border of the inner third of the clavicle the first 
incision is made about three inches in length, which is joined by one of 
the same length along the anterior edge of the sterno-mastoid muscle, 
the two joining at an acute angle. The skin and superficial fascia having 
been divided, the flap is dissected up. The sterno-hyoid and sterno- 
thyroid muscles, with a few fibres of the sterno-mastoid, are separated from 
the sternum, care being taken of the anterior jugular vein as it passes 
behind the last-named muscle at its origin, which may have to be divided ; 
if so, it should be secured by two small ligatures and divided between 
them. The deep cervical fascia is now exposed and divided in the line 
of the external wound, and the common carotid artery sought for, its 
sheath opened as low down as possible, and this artery followed until its 
junction with the subclavian is reached. 
According to Jacobson, the engorgement of the venous circulation, 
increased by the anaesthetic, will cause the internal jugular and the 
innominate veins to protrude through the wound. The artery may be 
flattened out by an aneurism, making it difficult of recognition ; and the 
cellular tissue around the vessel and between it and the sternum may be 
so matted with adhesions as to make it difficult to define the artery and 
its important surroundings—viz. the par vagum, pleura, and innominate 
vein. The artery must be cleared with the utmost caution, especially 
on the outer side; the par vagum and innominate vein may be drawn to 
the outside. The aneurism-needle should be passed from without in, 
and a little from below upward, so as to avoid the pleura as much as pos- 
sible. Several aneurism-needles with different curves should be at hand, 
and a laryngeal mirror will be a valuable aid. 
Ligature of the Common Carotid below the Omo-hyoid Muscle. 
—The patient is placed as in the former operation, the head turned 
slightly to the opposite side, and the hand of the affected side placed 
behind the back. An incision is made about three inches in length over 
the course of the artery, commencing a little below the cricoid cartilage 
and extending to just above the sterno-clavicular articulation, following 
the inner border of the sterno-mastoid muscle, which is exposed and 
drawn outward; the sterno-hyoid and sterno-thyroid are drawn to the 
inner side ; the omo-hyoid, if brought into view, is pushed upward. The 
communicating vein from the facial to the anterior jugular and the latter 
vein must be avoided,and the inferior thyroid veins may give some trouble. 
Retractors are needed and a good light is essential. The sheath is opened 
on the inner side, and care must be taken to avoid the descendens noni 
nerve. The needle is passed from within outward. On the left side the 
internal jugular vein may complicate the operation. 
Ligature above the Omo-hyoid Muscle.—Position of the patient 
same as in the preceding operation. Incision, about three inches in 
length, with its centre level with the cricoid cartilage, is made over the 
course of the artery. The skin and platysma having been cut through 
(together with branches of the superior cervical nerve), the deep fascia 
along the anterior border of the sterno-mastoid is cut through. The 
edge of this muscle having been made out, it must be followed down 
until the omo-hyoid is reached. The communicating vein from the LIGATION OF ARTERIES. 
137 
facial and the anterior jugular must be avoided. The sterno-mastoid 
may be drawn a little outward and the omo-hyoid downward, and the 
angle between the two muscles well cleared. The pulsations of the 
artery should now be sought, and the vessel can be readily detected as 
it crosses the “ carotid tubercle.” The carotid tubercle is the anterior 
projection of the transverse process of the sixth cervical vertebra, and 
Fig. 53. 
Surgical anatomy of the neck; ligation of the carotid, lingual, and facial arteries (Bernard and 
Huette). 
is about two inches above the clavicle. The sterno-mastoid artery and 
the superior and middle thyroid veins must be avoided, and care taken of 
the descendens noni nerve. The needle is passed from without inward. 
Ligature of the External Carotid.—Position of the patient same 
as in the preceding operations. An incision from near the angle of the 138 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
jaw, along the line of the artery, is made, terminating about even with 
the middle of the thyroid cartilage. The greater cornu of the hyoid 
bone will be about the centre of the incision. The integument and pla- 
tysma having been divided and superficial veins secured, the fascia is 
next divided, and the anterior border of the sterno-mastoid exposed at 
the lower part of the incision, which must be drawn outward. The pos- 
terior belly of the digastric is next cleared at the upper angle of the wound, 
and the hypoglossal nerve below it exposed, being careful not to injure 
it. With the finger the great cornu of the hyoid must now be sought, 
and the artery will be found and can be readily exposed opposite its 
tip, and can be ligated between the superior thyroid and lingual arteries, 
or below the latter if necessary. The facial and superior thyroid veins 
must be avoided, and lymphatic glands may lie in front of the artery. 
The artery having been cleared, the needle is passed from within out- 
ward, taking care not to include the superior laryngeal nerve, which 
passes down behind the artery. 
If it is desired to ligate above the digastric muscle, or the operation 
“ behind the ramus of the jaw,” the method is thus given by Jacobson : 
The head and shoulders being duly raised and supported, the surgeon 
makes an incision downward from the tragus of the ear just behind the 
ramus of the jaw, dividing skin and fascia. The sterno-mastoid must 
now be drawn outward and the digastric and stylo-hyoid downward; 
and it will probably be needful to divide these muscles partially in order 
to secure the artery before it enters the parotid gland, which must be 
drawn upward and forward. The needle may be passed from either 
side. “ This operation,” says Jacobson, “ has the disadvantage of 
probably entailing division of important branches of the facial nerve.” 
Wyeth says: “ The common carotid should never be tied for a lesion 
of the external carotid or its branches when there is room between the 
lesion and the division of the common carotid to permit the ligature of 
the external vessel ” (Figs. 53 and 54). 
Ligature of the superior thyroid artery is in all essential particulars similar to 
that of the external carotid below the digastric muscle, the needle being passed 
from above downward, care being taken to avoid the superior laryngeal nerve. 
The plexus formed by the thyroid veins may give trouble. 
Ligature of the Lingual Artery at its First Part.—Position of 
patient same as in operation on the common carotid; incision similar, 
though shorter, with its centre opposite the body of the hyoid bone. The 
external carotid is sought for, and carefully followed until the lingual 
is reached. The wound will be deep, and the first portion of the vessel 
more or less obscured by numerous veins (Pigs. 53 and 54). 
Ligature at the point of election or beneath the hyo-glossus muscle 
is thus described by Treves: “ The patient lies close to the edge of the 
table, with the shoulders raised and the face turned to the opposite side, 
with the arm of the affected side placed behind the back. An assistant 
must keep the chin well drawn upward and the lower jaw fixed. The 
surgeon stands on the side to be operated on. The chief assistant is 
placed opposite to him, and leans over the patient’s body. A second 
assistant stands by the surgeon’s side. His chief duty is to hold the 
hook which commands the digastric tendon. Full anaesthesia and the 
skin of the submaxillary region in the male shaved. An incision some 139 
LIGATION OF ARTERIES. 
two inches in length, curved and with the convexity downward, is made 
between the lower jaw and hyoid bone, commencing a little below and 
to the outer side of the symphysis, and ending a little below and to the 
inner side of the point where the facial artery crosses the lower margin 
of the maxilla. Its centre is just above the greater cornu of the hyoid 
bone. On the right side the incision is made from behind forward, and 
on the opposite side from before backward. The integument, platysma, 
and superficial fascia are divided in the line of the incision. Certain 
superficial veins will be encountered, and some will probably liave to 
be secured. These are the submental or other tributary veins of the 
facial, or some tributary of the anterior jugular. It will now be 
convenient to resort to retractors in order that the depths of the 
wound may be well laid open. The next step is to expose the sub- 
maxillary gland, lodged in a special compartment of the cervical fascia, 
which shonld be opened transversely over the lower part of the gland, 
the organ cleared and brought well out into the wound by means of the 
finger and the handle of the scalpel. The gland should be turned 
upward on to the margin of the jaw, and kept well out of the field by 
a broad and well-curved retractor held by the chief assistant. The 
fascia exposed by lifting out the salivary gland is now to be divided 
transversely, and in the anterior angle of the wound the posterior edge 
of the mylo-hyoid muscle must be sought for and defined. The digastric 
tendon and the two bellies of the muscle are now to be brought clearly 
into view. Around the tendon, which is nearest to the hyoid bone, a 
small blunt hook, with a very long shaft or handle, is to be passed and 
held by the assistant who stands at the surgeon’s side. The tendon 
should be drawn downward and toward the surface. The hyo-glossus 
muscle can now be easily made out, and its exposed surface freed of 
connective tissue. The hypo-glossal nerve must be sought for as it 
crosses the muscle, and the surgeon’s work limited to the segment of 
muscle below the nerve. Crossing the hyo-glossus below the nerve, 
and parallel with it, is the ranine vein. This vein will about corre- 
spond in position with the artery, which lies beneath the muscle. I he 
vein and nerve should be displaced upward. The hyo-glossus muscle 
is divided transversely, to the extent of half an inch, a little above the 
margin of the hyoid bone and parallel with it. The incision in the 
muscular tissue must be cautiously deepened. If the cut has been we 
placed, the artery will bend out into th§ wound and make itself evident 
as soon as the whole thickness of the muscle has been divided. The 
needle, unthreaded, is most conveniently passed from above downward 
In the ligature the minute vense comites winch attend the artery are no 
doubt included.” , , .. . ... • •!„_ 
Ligature of the facial artery may be placed by an incision sum a 
to that exposing the external carotid or the first part of tJiepllj^a '• 
is more conveniently secured as it crosses the margin o ‘ j 
A horizontal incision is made over the course of the arteiv, along i 
just under the inferior margin of the jaw, one inch m length, 
find the artery crossing the bone at the anterior border of the nageter 
muscle. It is only necessary to divide the skin, plasma, and fascun 
The facial vein is behind the artery and very close to it Hie nee 
should be passed from behind forward (Figs. 53 and - ). 140 
SURGICAL DISEASES AND INJURIES OF TIIE HEART. 
Ligature of the temporal artery is applied by an incision, one inch 
long vertically, over the course of the artery, between the tragus and 
condyle of the lower jaw. It is only covered by skin and dense fascia, 
a single large vein lying behind and overlapping it. Temporo-facial 
branches of the facial nerve cross the artery, which lies behind the 
auriculo-temporal nerve. The ligature should be passed from behind 
forward. 
Ligature of the occipital artery may be applied close to its origin 
and also back of the mastoid process. In the first position an incision 
similar to that exposing the external carotid at its upper part will suffice. 
In the second position an incision nearly horizontal, two inches long, is 
made, commencing at the tip of the mastoid process and carried back- 
ward and a little upward. The skin and fascia having been divided, 
the posterior fibres of the sterno-mastoid are cut; next the splenius is 
divided, and so much of the trachelo-mastoid as many be necessary. The 
artery is then felt and exposed in the interval between the mastoid pro- 
cess and the transverse process of the atlas, which can be felt with the 
finger. The needle can be passed either from above or below. 
Ligature of the Internal Carotid.—Position of the patient and ope- 
rator same as in operation on the external carotid at its lower point, and 
the incision is also almost similar, being a little more to the outside. 
The anterior edge of the sterno-mastoid is exposed and drawn outward. 
The external carotid is found and followed down to its junction with 
the internal, and drawn gently inward with a blunt hook. The digas- 
tric muscle is drawn upward. The sheath of the vessels is opened with 
care, and the needle passed from without inward, observing the same 
care as in ligating the common trunk. The internal jugular vein, the 
par vagum, the sympathetic ganglion, and the ascending pharyngeal 
artery, all lying close to the artery at this point, must be avoided. The 
internal differs from the external in giving off no branches in this part 
of its course (Figs. 53 and 54). 
Ligature of the Vertebral Artery.—Position of the patient same as 
in ligation of the external carotid. An incision commencing at the 
clavicle is carried up along the outer edge of the sterno-mastoid muscle 
for three inches, dividing the skin and superficial fascia; a few fibres 
of the attachment of the sterno-mastoid must be severed close to the 
clavicle. The dee]) fascia having been severed, the sterno-mastoid 
muscle and anterior jugular veins are drawn inward. The scalenus 
anticus muscle is next found, and the interval between it and the longus 
colli muscle entered with the finger, the position of the common carotid 
and internal jugular vein made out, and the transverse processes of the 
sixth and seventh cervical vertebrae located; below that of the former 
the artery should be felt. The various structures must be pushed to 
one or the other side. The vertebral vein lies in front. Care must be 
taken not to damage the inferior vessels, the pleura, or the thoracic 
duct on the left side. The needle is passed from without inward. 
Ligature of the Inferior Thyroid Artery.—An incision three inches 
in length along the inner edge of the sterno-mastoid muscle, as in liga- 
tion of the common carotid, low down, the wound reaching down to 
the clavicle. The sterno-mastoid is drawn outward, and the carotid 
artery and its vein are also drawn gently outward. The transverse LIGATION OF ARTERIES. 
141 
process of the sixth cervical vertebra is now carefully sought, a little 
below which the artery may be found, passing inward behind the carotid, 
close to which vessel the ligature is applied, thus avoiding the recurrent 
laryngeal nerve. 
Ligature of the Subclavian Artery.—While the ligature has been 
applied to the first and second portions of the subclavian, it is now 
Fig. 55. 
Surgical anatomy and ligation of the axillary and subclavian arteries (Bernard and Huette), 
almost exclusively limited to the third part, which comprises that seg- 
ment of the vessel crossing the posterior triangle of the neck and where 
it is most superficial. The base of this triangle is formed by the outer 
edge of the scalenus anticus muscle and the sides by the omo-hyoid 
muscle and the clavicle, the latter muscle being about one inch above 
the bone (Figs. 55 and 56). 142 
SURGICAL DISEASES AND INJURIES OE THE HEART. 
The artery here is covered by skin and the platysma, the cervical 
fascia, and a fibrous expansion extending from the omo-hyoid muscle to 
the clavicle, and rests upon the first rib, with the scalenus muscle behind 
and cords of the brachial plexus of nerves above, that one derived from 
the eighth cervical and first dorsal nerve being nearest the artery. The 
subclavian vein is below and anterior to the artery, passing in front of 
the scalenus anticus. 
The external jugular vein is usually in front of the artery, though 
its position may vary: the transverse cervical and suprascapsular veins, 
entering it here, may form a plexus over the artery. 
The suprascapular artery lies behind, covered with the clavicle, and 
the transverse cervical artery crosses beneath the omo-hyoid muscle at 
some distance above the main vessel. Normally, there is no branch 
given oil* from the subclavian at this part. In ligating the subclavian 
in the third part of its course the patient lies on the back, near the edge 
of the table, with thorax raised and head extended and turned to the 
opposite side, the arm pulled well down, passed behind the back, and 
securely fixed. The operator stands in front of the shoulder, a good 
light being essential. 
Drawing the skin over the posterior triangle well down with the left 
hand, an incision is made through it, reaching the clavicle. The incision, 
parallel with the clavicle, should be about three inches in length, and 
when the downward traction of the skin is withdrawn should be about 
one inch above the clavicle, extending across the base of the posterior 
triangle from the trapezius to the sterno-mastoid, with the centre of the 
wound even with a point about one inch to the inner side of the centre 
of the clavicle. The integument, the platysma, and supraclavicular 
nerves, with, possibly, a vein passing over the clavicle connecting the 
cephalic vein with the internal jugular, are divided by the incision. 
The amount of the trapezius and sterno-mastoid exposed will depend 
upon the extent to which they are attached to the clavicle (Figs. 55 
and 56). 
The deep cervical fascia is next divided the extent of the primary 
incision, carefully and without the aid of a grooved director. If the 
external jugular vein cannot be drawn to one side with a blunt hook, 
it should be divided between two ligatures and all bleeding vessels 
secured. 
The outer margin of the scalenus anticus should next be made elear, 
and the position of the omo-hyoid developed, and if at all in the way it 
must be drawn upward. The finger should be passed along the edge of 
the scalene muscle until the tubercle of the first rib is reached, when it 
will be in contact with the artery and its pulsations felt, the vessel rest- 
ing on the rib. A little careful dissection will clear the artery and 
bring into view the lowest cord of the brachial plexus, which should be 
systematically exposed by a slight but careful dissection. The sub- 
clavian vein will be seen and felt, but it does not encroach upon the 
field of operation. The needle may now be carefully passed from above 
downward and from behind forward, its course guided by the fore finger 
of the left hand, protecting and holding the vein out of the way. 
In some cases portions of the trapezius and sterno-mastoid may have 
to be cut. The transverse cervical or suprascapular arteries may be in LIGATION OF ARTERIES. 
143 
the way, and must be drawn aside, and in no instance cut, as they per- 
form an important part in the collateral circulation. 
If the patient is stout with short neck, the difficulties will be en- 
hanced. A plexiform arrangement of the veins, their engorgement, 
matting together and oedematous condition of the tissues greatly increase 
Fig. 57. 
Fig. 58. 
Surgical anatomy of the axilla and ligation of the axillary artery (Bernard and Huette). 
the difficulties. The pleura must be carefully avoided in passing the 
needle, as well as the lower cord of the brachial plexus. 
Ligature of the axillary artery is practically limited to its third 
part. The course of the artery will be covered by a line from the cen- 
tre of the clavicle to the humerus, close to the border of the coraco- 144 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
brachialis muscle, when the arm is so abducted as to be at right angles 
to the body (Figs. 55-58). 
The patient is placed upon the back, close to the edge of the table, 
with the shoulders raised, the arm at right angles to the body and held 
horizontally, the surgeon placing himself between the arm and the thorax. 
The axilla having been shaved, an incision about three inches in 
length is made along the course of the artery, commencing at the middle 
of the outlet of the axilla, at the junction of the anterior and middle 
thirds, and continued downward along the inner margin of the coraco- 
brachialis muscle. The knife should be held with the blade horizontal, 
and the coraeo-brachialis thoroughly exposed after skin and fascia 
have been divided. This muscle, with the musculo-cutaneous nerve, is 
gently drawn outward, when the position of the artery may be deter- 
mined with the finger. In clearing the artery the median nerve is 
exposed, and should be drawn outward with a blunt hook, and the inter- 
nal cutaneous nerve pushed to the inner side. The venae comites having 
been well demonstrated, the needle is passed from within outward. 
Ligature of the Brachial Artery at the Middle of the Arm.—The 
limb should be extended and abducted, with the band supine and held 
away from the body, the arm itself unsupported, but the limb held 
securely by an assistant grasping the forearm. The surgeon stands on 
the outside of the limb on the right side and between the body and the 
limb on the left, making his incision from above downward. The 
incision, about two and a half inches in length, should be made along 
the inner edge of the biceps muscle in the line of the artery. The 
fascia, which is here thin, is exposed and divided, and, the muscular 
layer reached, the inner edge of the biceps clearly exposed and defined. 
The muscle is displaced slightly outward, and the pulsation of the ves- 
sel sought. If the median nerve is not brought into view, a little dis- 
section will clear it: in the middle of the arm it usually lies in front of 
the artery, and should be displaced gently to the outside: below the 
middle of the arm it is more conveniently displaced inward. AVhile 
the artery is being exposed the elbow may be slightly and moderately 
flexed (Figs. 59 and 60). 
The sheath of the vessel having been opened, the venae comites sepa- 
rated as well as possible, the inner one usually being the larger, the 
needle is passed from the median nerve. 
In the upper part of its course the inner margin of the coraco-bra- 
chialis is exposed instead of the biceps, and the ulnar nerve will be 
found lying to the inner side of the vessel. 
Ligature of the Brachial Artery at the Bend of the Elbow.—The 
limb, extended and abducted, may be allowed to rest on the olecranon. 
It should never be over-extended. An incision, two inches in length, 
with its middle in the centre of the “fold of the elbow,” is made 
through the skin along the inner edge of the biceps and parallel with its 
margin. The upper end of the incision will be on a level with the tip 
of the internal condyle, and will extend obliquely downward and to- 
ward the centre of the arm (Figs. 59 and 60). 
If the veins are normally placed, the incision will lie to the outer 
side of the median basilic and nearly parallel with it. As soon as the 
vein is exposed it should be drawn inward, and the bicipital fascia LIGATION OF ARTERIES. 
145 
divided in the line of the original incision. Its fibres will be found 
extending obliquely downward and inward. The artery, with its venae 
comites, being now exposed, the veins are separated and the needle 
passed from within outward. The vessel here is quite movable and free 
from attachments. The median nerve is not exposed, and is nearest the 
artery (on its inner side) at the upper part of the wound. 
Ligature of the radial artery may be applied at the upper, middle, 
Fig. 59. 
Fig. 60. 
Surgical anatomy and ligation of the brachial artery (Bernard and Iluette), 
and lower third of its course. The radial continues the line of the 
brachial, and a line extending from the middle of the bend of the elbow 
to the gap between the scaphoid bone and the extensor ossis pollicis and 
extensor internodii pollicis will give its position reasonably definite. 
In the upper third of the forearm an incision two and a half inches 
in length is made in the line of the artery. The radial or other surface 
vein may be encountered. After the deep fascia is divided the interval 146 
SURGICAL DISEASES ANI) INJURIES OE TIIE HEART. 
between the supinator longus and pronator teres is opened up, the fibres 
of the supinator being vertical and those of the pronator oblique. 
Beneath the supinator the vessel will be found unaccompanied by the 
nerve. The needle can be passed from either side. The limb is supin- 
ated, and firmly held by an assistant grasping the hand and arm. The 
surgeon stands on the side to be operated on (Figs. 61 and 62). 
In the middle third, the limb placed as above, an incision two inches 
in length is made along the course of the artery, any superficial veins 
from the median or radial being avoided. The anterior division of the 
musculo-cutaneous nerve lies usually in the line of the artery between 
the superficial and deep fascia, and must be held aside. The fibres of 
the superficial fascia run longitudinally, and those of the deep fascia 
transverse. The deep fascia, being made clear, is divided the length of 
the superficial incision, and the supinator longus is exposed about the 
point where it becomes tendinous. The ulnar border of this muscle is 
defined and drawn outward; the elbow being slightly flexed will allow 
this to be done more easily, and the vessel will be found lying upon the 
insertion of the pronator radii teres, with which it is connected by con- 
siderable connective tissue. The nerve may or may not be seen. The 
vente comites being separated as well as possible, the needle is passed 
from either side. 
In the lower third, with position as before, an incision one and a 
quarter inches long is made over the line of the artery at the point 
where the pulse is usually felt, parallel with and between the supinator 
longus and flexor carpi radialis muscles, but must not extend below the 
tuberosity of the scaphoid (Figs. 61 and 62). 
The commencement of the radial vein lies over the artery and must 
be avoided. The fascia, which is here quite thin, is divided in the course 
of the superficial incision, and the gap between the two tendons made 
out. The terminal part of the anterior division of the external cutane- 
ous nerve is over the artery and in close relation. If it is found impos- 
sible to separate the venae eomites sufficiently to let the needle pass, they 
may be included in the ligature. 
Ligature of the Ulnar Artery.—This vessel, larger than the radial, 
follows a curved course in the upper third of the limb, and perfectly 
straight the remaining two-thirds. It lies too deeply for ligature in 
the upper third, except for arrest of hemorrhage when cut or divided, 
and the operation of election is left for the middle and lower third. It 
may be ligated, however, close to the origin of the brachial, if needed, 
by slightly extending downward the incision for ligating this vessel at 
the end of the elbow (Figs. 61 and 62). 
The artery in the lower two-thirds of its course will be found beneath 
a line drawn from the tip of the internal condyle of the humerus to the 
radial side of the pisiform bone. 
In applying a ligature in the middle third the position is the same 
as in ligation of the radial. An incision two and a half to three inches 
in length, according to the size of the limb, is made over the line of 
the artery. Branches of the anterior division of the internal cutaneous 
nerve and the ulnar vein are apt to be encountered. 
The deep fascia is thin, and is to be divided the length of, but a little 
to the outside of, the incision in the skin. The gap between the flexor LIGATION OF ARTERIES. 
147 
carpi ulnaris and the flexor sublimis digitorum is now to be made out 
by the sense of touch communicated to the fore finger. As soon as the 
intermuscular space is detected the wrist should be slightly flexed to 
relax the muscles, and with broad retractors the flexor carpi ulnaris is 
drawn inward and the flexor sublimis digitorum slightly outward, and 
the intermuscular space opened up, at the bottom of which will probably 
Fig. 61. 
Fig. 62. 
Surgical anatomy and ligation of the radial and ulnar vessels (Bernard and Huette) 
be found the ulnar nerve, to the outer side of which is the artery. The 
fascia binding the vessels is slight, and the venae comites are readily 
separated. The needle should be passed from within outward to avoid 
the nerve. The interspace between the two muscles is not exactly ver- 
tical with the limb in position for the operation, the flexor carpi ulnaris 
slightly overlapping the flexor sublimis, and the interspace is to be 148 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
followed down in a direction slanting toward the outer side of the ulna. 
In very muscular subjects the incision must be made sufficiently long. 
In the lower third, the arm being in the same position, a ligature is 
applied by means of an incision two inches long over the line of the 
artery, just to the radial side of the tendon of the flexor carpi ulnar is, 
terminating an inch or less above the pisiform bone. Care must be 
taken to avoid tributaries of the ulnar vein which may overlie the 
artery. The deep fascia, here quite slender, is exposed and divided, and 
the tendon of the flexor carpi ulnaris made out and drawn gently inward 
by a blunt hook, the wrist being slightly flexed. The vessel will now 
be found bound down to the flexor profundus by a distinct layer of 
fascia, which must be carefully divided. The nerve is close to the 
artery on its inner side. It may be necessary to include the venae 
comites in the ligature, which is passed from within outward. The 
palmer cutaneous nerve lies upon the artery in this location and must 
be avoided. The tendon of the flexor carpi ulnaris has muscular fibres 
entering it on the radial side down to the wrist—on the ulnar side it is 
quite clear (Figs. 61 and 62). 
Ligation of the palmar arch and branches of it and the radial or 
ulnar arteries is only required for traumatisms, the nature of which will 
determine the method of application. 
Ligation of the Abdominal Aorta.—The eleven cases of ligation of 
the abdominal aorta having all terminated fatally, it is, in my opinion, 
an unjustifiable operation, affording neither hope to the patient nor fclat 
to the surgeon; consequently it is only mentioned to be condemned. 
Ligation of the common iliac artery can be performed by an ante- 
rior or lateral incision or by the intraperitoneal method : the latter is con- 
sidered by Treves as the best, though it has not yet been satisfactorily 
tested. It can be carried out by the intraperitoneal method of reaching 
the internal iliac, to be subsequently considered. 
In the anterior incision the bowels should be thoroughly evacuated, 
any gaseous distention relieved if possible, and the pubes well shaved. 
The patient lies on the back, with thighs well extended and close 
together, with the head and shoulders slightly raised to relax the 
abdominal parietes. The surgeon stands on the side to be operated on, 
facing the patient, cutting from above downward on the right and in an 
opposite method on the left. An assistant, to whom is entrusted the 
care of the broad retractor to be used, stands on the opposite side. 
An incision five inches in length is made, commencing one and one- 
fourth inches to the outer side of the spine of the pubes, a little above 
Poupart’s ligament, the first inch and a half being made parallel with 
the ligament, when the incision is curved slowly upward, perpendicular 
to the ligament, terminating about one and a quarter inches to the out- 
side of the umbilicus. The three abdominal muscles and the trans- 
versalis fascia are divided carefully; the peritoneum is carefully and 
gently stripped from the iliac fossa with the fingers, pushed inward, and 
held out of the way with a broad retractor: the patient may be turned 
to the opposite side to aid in keeping the intestines out of the way. A 
strong needle, of good length, with lateral curve, will be found most 
available, which should be passed from within outward. The vein lies 
directly behind on the right, and to the inner side and slightly behind LIGATION OF ARTERIES. 
149 
on the left. Great care must be taken to avoid injury to the perito- 
neum. 
Ligature of the internal iliac artery is accomplished by the extra- 
or intraperitoneal method. The extraperitoneal method is identical 
with the anterior operation on the common iliac previously described. 
The peritoneum having been pushed aside until the external iliac is 
reached, this vessel is followed down to its junction with the internal. 
The wound is deep, and several varieties of needles with different curves 
should be at hand, and on either artery the needle should be passed from 
within out. 
By the intraperitoneal method the abdomen is opened in the median 
line by an incision extending from symphysis to umbilicus, or a little 
above in fleshy subjects. The intestines having been pushed up and 
drawn aside, the area of the deep wound is surrounded by aseptic gauze 
mats, preferable to flat sponges, and so cut off from the peritoneal cavity. 
The wound being held well open by broad retractors or spatulse, the 
peritoneum over the artery is divided to the extent of an inch and a 
half, and the common artery followed down to its bifurcation. The vein 
is much larger than the artery, and the separation will require care. 
The ureter must not be injured or included in the ligature, and sympa- 
thetic nerve-fibres must be avoided. 
Ligature of the Sciatic or Internal Pudic Arteries.—The patient, 
having been anaesthetized, is rolled over on to the face, the limb drawn over 
the edge of the table, and the thigh rotated in. A line drawn from the 
posterior iliac spine to the outer part of the tuberosity of the ischium, 
at the junction of its middle with its lower third, will cover the point 
of emergence of these arteries from the pelvis. An incision four inches 
in length is made obliquely across this line in the direction of the fibres 
of the gluteus maximus, its centre corresponding to the point above 
mentioned. The gluteus maximus is divided in the line of the wound, 
and the lower margin of the pyriformis muscle and the spine of the 
ischium well defined. The arteries will be found in front of the pyri- 
formis muscle: near its lower margin the sciatic is superficial to the 
pudic, and passes behind it to gain the outer side. Venae comites 
accompany both vessels. To the inner side of the pudic at this point 
lie the internal pudic nerve and its inferior hemorrhoidal branch. The 
sciatic here is superficial to both the great and small sciatic nerves. The 
ligature should be placed as near the pelvis as possible. 
Ligature of the Gluteal Artery.—Position as in the preceding ope- 
ration. With the thigh rotated in, a point at the junction of the upper 
with the middle third of a line drawn from the posterior iliac spine to 
the top of the great trochanter will overlie the gluteal artery as it 
emerges from the sciatic notch. An incision five inches in length, with 
the centre over the above-mentioned point, is made along this line. The 
incision runs parallel with the fibres of the gluteus maximus, which are 
separated the thickness of the muscle. A muscular branch may be met 
with which will serve as a guide to the trunk. The deep fascia between 
the glutei is divided, and the contiguous borders of the gluteus medius 
and pyriformis cleared, and the two muscles separated and held apart 
with retractors. The superficial division of the artery passes between 
these two muscles, and is followed down to the main trunk. Care must 150 
SURGICAL DISEASES ANI) INJURIES OF THE HEART. 
be taken to avoid the vein and nerve, and the ligature should be placed 
as far within the notch as possible, almost within the pelvis, as the artery 
divides soon after emerging therefrom. Some fibres of the great sacro- 
sciatic ligament may have to be divided. 
Ligature of the External Iliac Artery.—The modified form of Sir 
Fig. 63. 
Fig. 64. 
Fig. 65. 
Surgical anatomy and ligation of the femoral, external iliac, and epigastric arteries (Bernard and 
Huette). 
Astley Cooper’s operation is as follows: The patient lying on the back, 
head and shoulders slightly raised, an incision is made three and a half 
inches long above Poupart’s ligament. The incision, slightly curved, 
beginning one and a quarter inches outside the pubic spine, runs for 
two-thirds of its course about three-eighths of an inch above the 
ligament and parallel with it, the outer third curving slightly away from LIGATION OF ARTERIES. 
151 
the ligament. The skin and superficial tissues having been cut through 
and the divided superficial epigastric artery secured by ligature, torsion, 
or pressure-forceps, the white, glistening aponeurosis of the external 
oblique now brought into view is divided in the line of the primary 
incision, following very nearly the direction of its fibres. The parts 
being retracted, the outer border of the conjoined tendon is made out at 
the inner angle of the wound. The lower fibres of the internal oblique 
are divided close to their attachment to Poupart’s ligament as far as 
necessary. The transversalis muscle is attached only to the outer third 
of the ligament (Figs. 63—65). 
The transversalis fascia, being exposed, is divided transversely over 
the artery and as far on either side as necessary. The deep epigastric 
artery lying between this fascia and the peritoneum must be avoided. 
The external iliac artery now being made out, the subperitoneal tis- 
sue about the vessels should be carefully loosened, and the peritoneum 
pulled from the artery and vein with the utmost care and pushed 
upward toward the umbilicus, and held out of the way with a broad 
retractor. The loose subperitoneal tissue, which forms a kind of sheath 
for the artery, should be cautiously cleared away and the needle passed 
from within outward. In closing the wound the divided fibres of the 
internal oblique may be attached to Poupart’s ligament, and the aponeu- 
rosis of the external oblique united by a few catgut sutures. 
Abernethy’s operation is described in South’s Chelius as follows: 
“ An incision four inches in length, commencing one and a half inches 
above and to the inner side of the anterior superior iliac spine, is carried 
down, curving slightly, with concavity below, to within half an inch of 
Poupart’s ligament, a little below its centre. The muscles are divided 
in order, the peritoneum exposed and pushed back as in the former 
method, and the vessel reached. This method enables one to reach the 
artery higher up, but Cooper’s operation is more easily performed.” 
Ligation of the femoral artery is usually performed at the base of 
Scarpa’s triangle, at its apex, and in Hunter’s canal. With the hip a little 
flexed and the thigh abducted and rotated outward, a line drawn from 
midway between the anterior superior spine of the ilium and the sym- 
physis pubis to the tuberosity of the internal condyle will indicate its 
course. The centre of Poupart’s ligament is to the outer side of the line 
of the vessels. 
Ligation of the common femoral is best done at the base of Scarpa’s 
triangle. The patient lies upon the back, with the hips a little flexed, 
the thigh abducted and rotated outward, the knee bent, and the leg rest- 
ing on its external surface. The surgeon stands on the outer side of the 
limb, and cuts from above downward on the right, and vice versa, on the 
left. An assistant stands on the opposite side (Figs. 63-67). 
An incision two inches in length, commencing just above the centre 
of Poupart’s ligament, is made downward directly over the course of the 
artery. The fatty tissue covering the fascia lata having been reached, 
is divided, care being taken not to injure any of the lymphatic nodes 
and the superficial epigastric and superficial circumflex iliac veins. The 
cribriform fascia is divided in the line of the original wound, especial 
care being taken to avoid the superior external pubic, the superficial 
epigastric, or other arterial branches. The crural branch of the genito- 152 
SURGICAL DISEASES ANI) INJURIES OF THE HEART. 
crural nerve lies on the sheath of the artery, on the outer side. The 
sheath being carefully opened, the needle is passed from the inner side. 
Ligation of the Superficial Femoral at the Apex of Scarpa’s Tri- 
angle.—Position same as in preceding operation. An incision over the line 
of the vessel, with its centre at the apex of the triangle, is made. Pres- 
sure, having previously been made over the saphenous vein where it joins 
the deep femoral, will outline the course of the superficial veins. The 
saphena will generally be to the inner side of the incision. The integu- 
Fig. 66. 
Fig. 67. 
Surgical anatomy and ligation of the femoral artery (Bernard and Huette) 
ment and superficial fascia having been divided, the deep fascia is 
divided and the inner border of the sartorius muscle is sought for, it 
being the guide to the artery, and is recognizable by the course of its 
fibres downward and inward, underneath which the sheath of the vessels 
will be found. The muscle, having been detached with the finger, is 
held outward with a retractor, exposing the sheath, the artery in front, 
and the vein behind, the long saphenous nerve generally, and sometimes 
a nerve to the vastus internus lying on the vessel. The sheath having 
been carefully opened, the needle is passed from within outward, caution LIGATION OF ARTERIES. 
153 
being used to avoid injury to the vein. If the vein is wounded by the 
needle, it should be closed by a small ligature and the ligature applied 
to the artery higher up. A needle curved laterally will be more readily 
passed under the vessel. 
Ligature of the Superficial Femoral in Hunter’s Canal.—Position 
same as in preceding operation. An incision three and a quarter inches 
long is made over the course of the vessels in the middle third of the thigh. 
In the subcutaneous tissue will be found the anterior division of the 
internal cutaneous nerve, and to its inner side the long saphenous vein, 
which must be drawn to the inner side. The fascia lata is now divided 
in the line of the primary incision, the sartorius muscle exposed, and 
its anterior outer edge drawn inward. The leg being now well abducted, 
making prominent the fibres of the adductor magnus and the lower 
border of the adductor longus, the site of Hunter’s canal, lying between 
the adductor magnus and the vastus intern us, will be well defined. 
Clearing away any fatty tissue that may obscure, the part of the fascia 
forming the roof of IIunter’s canal, with its fibres running transversely, 
will be made distinct. At this point, at the outer side of the wound, 
the nerve to the vastus interims must be looked for. Opening the canal 
in the line of the wound, the artery is exposed, and the needle may be 
passed from either side. In front and to the inner side will be found 
the internal saphenous nerve, which must be avoided and care taken not 
to injure the vein (Figs. 66 and 67). 
Ligature of the popliteal artery is rarely required. Bryant says r1 
u I hardly know under what circumstances this artery may require the 
application of a ligature, except for a wound; as for rupture of the 
artery or for aneurism, the operation is as inapplicable as it would be 
unsuccessful.” 
The vessel may be reached in its upper part by an incision along the 
outer border of the semi-membranosus muscle, and in its lower by an 
incision between the heads of the gastrocnemius. In the upper part the 
vein lies to the outer, and in the lower to the inner, side of the artery. 
The needle should be passed from without inward above, and from within 
outward below. The nerve is still more superficial, and above is still 
farther out, lying over the artery at the back of the knee, and to the 
inner side beneath the gastrocnemius. 
Ligature of the Posterior Tibial Artery.—A line drawn from the 
centre of the popliteal space to a point midway between the inner malle- 
olus and the heel will correspond to the lower half of the artery. The 
upper half curves slightly inward from this line. 
In operations on this artery the patient lies on the back, the knee 
flexed, the leg lying on the outer side, the feet on the table, secured in 
this position by an assistant. The surgeon stands on the outer side of 
limb (Figs. 68 and 69). 
In the middle of the calf an incision, four inches in length, in the 
middle third of the leg is made, parallel to the inner margin of the 
tibia and three-quarters of an inch behind its crest. After dividing the 
skin care must be taken not to injure the internal saphenous vein, which 
should be drawn aside. The fibres of the deep fascia, all of which are 
transverse, are divided and the margin of the gastrocnemius brought into 
1 Surgery, p. 376. 154 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
view. The soleus is next exposed and divided the length of the incision, 
the aponeurosis with its fleshy fibres being cut through. Here the knife 
should be held perpendicular to the muscle, its edge directed toward the 
tibia and the blade nearly horizontal. The fascia covering the vessels 
and the deep muscles of the leg is now exposed, and the artery can be 
felt lying near the outer border of the tibia. The nerve lies to the outer 
Fig. 68. 
Fig. 69. 
Surgical anatomy and ligation of the posterior tibia! artery (Bernard and Huette) 
side of the artery. The veins are very conspicuous, and may hide the 
vessel, and in all probability will have to be included in the ligature. 
The needle must be passed from the nerve. 
Ligature in the lower third of the leg is applied by an incision two 
inches in length along the line of the artery midway between the margin 
of the tendo Achillis and the inner edge of the tibia. The superficial 
and deep fascia are divided, as well as the annular ligament at its upper LIGATION OF ARTERIES. 
155 
part. The artery will be found lying on the flexor longus digitorum 
muscle, with the nerve to the outer side. The needle is passed from the 
nerve, and the venae comites may have to be included. 
Ligature behind the Malleolus.—A curved incision, two inches long, 
is made about one-half an inch behind and parallel with the margin of 
the inner malleolus, the knife being directed toward the tibia. The 
internal annular ligament is divided over the artery. The vessels and 
nerve lie in a gap between the tendons, and can be readily made out by 
the touch. Separating the artery from the vein, the needle is passed 
from within outward (Figs. 68 and 69). 
Ligature of the Peroneal Artery.—The patient lies upon the sound 
side, almost on the abdomen, with the knee slightly flexed and the leg 
held firmly on the table on its antero-internal surface. An incision, 
three and half inches long, is made parallel with and immediately 
behind the outer border of the fibula, the centre of the incision corre- 
sponding to the middle of the leg. The fascia having been divided, the 
soleus muscle is exposed and drawn inward. It may be necessary to 
sever the lower fibres of this muscle which arise from the upper third 
of the fibula. Drawing it aside, exposing the fibula, the fibres of the 
flexor longus pollicis are severed close to the fibula until the mem- 
branous wall of the canal enclosing the vessels is exposed. Carefully 
laying this open, the artery is found lying against the inner margin of 
the fibula. The needle may be passed from either side, including the 
venae comites (Figs. 70 and 71). 
Ligature of the Anterior Tibial Artery.—The course of this artery 
will be found under a line from midway between the head of the fibula 
and the outer tuberosity of the tibia, extending down to the centre of 
the ankle-joint in front. The patient lies upon the back, the limb 
straight upon the table, fully rotated inward, with the foot projecting 
beyond the table and forcibly extended. 
In the upper third of the leg an incision, three and a half inches 
long, is made along the line of the artery, its upper end about one inch 
below the head of the tibia. The deep fascia is divided along the same 
line, and the interval between the tibialis anticus and the extensor com- 
munis digitorum made out. The foot is now flexed to relax these mus- 
cles, and the space between them opened up by finger or handle of 
scalpel, the external border of the tibia being distinctly made clear to 
the touch before the artery is sought for, the extenser communis being 
held down by the fingers of the left hand, while an assistant holds the 
tibialis anticus toward the tibia with a retractor (Figs. 70 and 71). 
The artery will be found lying on the interosseous membrane to the 
outer side of the border of the tibia, covered and held down by a mode- 
rately dense connective tissue. A second retractor now holds back the 
extensor communis, and the artery is exposed. The venae comites may 
have to be included in the ligature. The nerve lies to the outer side of 
the artery, and, as it sometimes does not join the artery until the middle 
third of the leg is reached, may not be seen. The needle is passed from 
without inward. 
In the middle third of the leg make an incision three inches long 
over the line of the artery. The deep fascia, being exposed, is divided 
in the interval between the tibialis anticus and the extensor communis 156 
SURGICAL DISEASES AND INJURIES OF THE HEART. 
digitorum, the latter being tendinous at this point. The foot is flexed 
and the muscles separated with the handle of the scalpel, keeping in the 
direction of the tibia. The artery will be found on the interosseous 
membrane, the extensor pollicis to the outer side. The nerve will be 
exposed before the artery is reached, as it lies in front of the vessels. 
The needle may be passed from either side. The venae comites may be 
Fig. 70. 
Fig. 71. 
Surgical anatomy and ligation of the anterior tibial and peroneal arteries (Bernard and Huette). 
included in the ligature, but the nerve must be carefully protected from 
injury (Figs. 70 and 71). 
Ligature in the lower third of the leg is applied by an incision two 
to two and a half inches in length over the line of the artery, and just 
to the outer side of the tendon of the tibialis anticus, identifying with 
certainty the tendon. The foot need not be quite so much rotated as in 
the preceding operation. The deep fascia, or upper band of the annular LIGATION OF ARTERIES. 
157 
ligament, is divided in the same line, and the tendons of the tibialis 
anticus and extensor pollicis exposed and defined. The artery will 
be found between them on the front of the tibia, imbedded in fatty con- 
nective tissue. The foot being slightly flexed, the tendon of the exten- 
sor pollicis is drawn to the outer side with a blunt hook, exposing the 
artery. The nerve lies to the outer side, and the needle should be passed 
from it. The venae comites can be readily separated (Figs. 70 and 71). 
Ligature of the Dorsalis Pedis Artery.—This vessel extends from 
the centre of the front of the ankle, midway between the malleoli, to 
the middle of the first interosseous space. The patient lying on the 
back, the heel is steadied firmly on the table. The surgeon stands on 
the outer side of the foot, cutting from above downward on the right, 
and vice versd on the left. 
An incision commencing at the lower border of the annular ligament, 
one and a half inches long, is made over the course of the artery, and will 
be between the tendons of the extensor pollicis and the inner tendon of the 
extensor communis digitorum. The dorsal fascia is divided in the same 
line, and the vessel will be found imbedded in the connective tissue 
close to the bone. The ankle should be slightly relaxed as the vessel 
is sought for. The needle should be passed from the outer side to 
avoid the nerve. CHAPTER IV. 
SURGICAL DISEASES AND INJURIES OF THE RESPIRATORY 
ORGANS. 
D. Bryson Delavan, M. D 
Inspection and palpation of the exterior of the neck in the neighborhood of 
the larynx and trachea will sometimes demonstrate deviations, deformities, and the 
degree of mobility of these organs. Auscultation of the larynx by means of the 
stethoscope is sometimes useful in cases of foreign bodies, tumors, and the like. 
Palpation applied to the pharynx and the entrance of the larynx is occasionally 
valuable. No method, however, is comparable with the laryngoscope, by which 
the interior of the larynx and trachea can be directly demonstrated. 
(Edematous laryngitis is a serous, sero-purulent, or purulent infil- 
tration of the submucous cellular tissue of the larynx, and is, practically 
speaking, an acute cellulitis. The frequency of its association with 
erysipelas has often been observed. The oedema may be situated above, 
at, or under the glottic aperture. It is generally above and in the 
aryteno-epiglottic folds and the ventricular bands, which, with the 
epiglottis, may become enormously swollen and entirely occlude the 
larynx. The swelling is usually bilateral. Unless resolution takes 
place the infiltration may become sero-purulent, and later purulent, 
resulting in abscess. 
(Edema of the larynx may be inflammatory or non-inflammatory, 
acute or chronic. 
The non-inflammatory form may occur from certain non-surgical 
causes. 
Inflammatory oedema may develop from an attack of acute catarrhal 
laryngitis or complicate erysipelas of the pharynx. 
Symptoms.—The chief local symptoms are dyspnoea, aphonia, dys- 
phagia, with, occasionally, cough, and a sensation of marked irritation 
in the throat. The laryngoscope reveals intense congestion of the larynx 
and often of the adjacent parts, with the characteristic swelling of the 
arytenoids and the epiglottis. The latter may attain such size as to 
entirely occlude the larynx, and thus produce asphyxia. The false vocal 
bands are sometimes implicated. The disease may be unilateral, but is 
more often symmetrical. 
Treatment must be prompt. In early stages applications of cold 
in and outside of the larynx, or, if better borne, steaming inhalations 
(tr. benzoin, co., acid, carbolic., or tr. opii, of either, jsj-Oij). The admin- 
istration of a slightly purgative dose of calomel is often valuable. Vocal 
and physical rest. To relieve temporarily, local applications of a 4 per 
cent, solution of cocaine. Should oedema become severe, scarification, per- 
formed with the concealed laryngeal knife, aided by larvngoscopic demon- 
158 INJURIES TO THE LARYNX. 
159 
stration of the parts, or with Buck’s scarificator. Following scarification, 
application of cocaine to the larynx, as suggested bv the writer, for the 
purpose of constricting the cedematous tissues and, if possible, emptying 
them. If necessary, quick tracheotomy, in which the simplest methods 
are permissible, for want of better, as long as the asphyxia is relieved. 
The value of the O’Dwyer tube in these cases has often been proved. 
Besides relieving the dyspnoea, its pressure upon the infiltrated parts 
may actually hasten the disappearance of the oedema. These cases 
should be watched throughout with the closest vigilance. 
Injuries to the Larynx. 
Contusion of the larynx lias sometimes been observed. Its results 
may be slight and limited to the rupture of a few submucous vessels, or 
extravasation may be extensive and dangerous. Complicating fractures 
or dislocations of the cartilages may cause rupture of blood-vessels, 
nerves, or ligaments. 
The symptoms are aphonia and dyspnoea, the latter sometimes severe. 
Laryngoscopic examination will usually reveal the nature and seat of 
the lesion. Treatment of moderate extravasation when seen early 
consists of local rest, cold, and application of astringents. 
Wounds of the larynx and trachea generally complicate more 
extensive injuries of the neck, involving division of the great vessels 
and speedy death. Sometimes the larynx or trachea may be wounded, 
the cervical vessels receding before the knife, and thus escaping injury. 
( Vide Chapter V.) 
Inflammation or septic infection is a more frequent source of danger 
in the smaller wounds, and in the larger ones necrosis, inhalation of 
detached fragments, growth of granulations, secondary hemorrhage, 
tracheo-bronchitis, pleurisy, and broncho-pneumonia. Death in from 
eleven to fourteen days, and recovery in uncomplicated ones in from 
thirty to forty. Defective voice, laryngeal stenosis, and tracheal fistula 
sometimes result. The prognosis is serious, especially in the case of 
small penetrating wounds. Treatment must be prompt and energetic. 
Union by first intention is unusual. Provision should therefore be made 
for drainage. Usually hemorrhage must be checked and asphyxia pre- 
vented. The air-passages must be cleared of blood, partly detached frag- 
ments of tissue removed, a tracheal cannula inserted, the strength of 
the patient sustained, and the indications in special cases actively met. 
Tracheotomy may be required, on account of asphyxia and to relieve 
hemorrhage, which the asphyxia increases. If necessary the tampon-can- 
nula should be employed. Some recommend a preventive tracheotomy 
where the constant attendance of a surgeon cannot be secured, in view 
of the danger of displacement of the wounded parts or of sudden 
oedema. This, however, is not always necessary. Sometimes the intro- 
duction of a large catheter or other suitable cannula may give the 
required relief. Where the wound is near the crico-thyroid space intu- 
bation may sometimes be valuable. 
Fracture of the Larynx.—Most common in men, and is generally 
due to direct violence. It may be simple or compound, incomplete or 
complete. The thyroid is most often implicated, the cricoid next, while 160 
DISEASES ANI) INJURIES OF THE RESPIRATORY ORGANS. 
fracture of both is unusual, and that of the arytenoids very rare. Frac- 
ture may be complicated with fractures and wounds of neighboring parts 
and with injury to the external jugular vein. 
The symptoms, varying in severity, are functional disturbance, 
expectoration of frothy blood or of bloody mucus at or shortly after 
the time of the accident, stridulous respiration, dyspnoea, more or less 
aphonia, dysphagia, and sharp pain in the larynx, increased on pressure. 
Inspection will reveal swelling and ecchymosis, and over the larynx 
itself various irregularities, with unusual flexibility, mobility, or even 
crepitation of the cartilages. All of the latter signs may be absent. 
The symptoms are sometimes slight and recovery speedy. Gener- 
ally, they are either severe from the first or gradually become so. 
Later, the danger is from abscess, necrosis of fragments, and the forma- 
tion of deforming cicatrices and consequent stenosis of the larynx. 
The prognosis is serious, and the rate of mortality very high, 
especially in fractures of the cricoid. Resulting cicatricial stenosis of 
the larynx may make the permanent wearing of a tracheal cannula 
necessary. 
Diagnosis is easy except where there is little displacement and 
much swelling. 
Treatment.—Several methods of treatment have been recom- 
mended : while some cases have recovered without surgical aid, trach- 
eotomy has generally been advised when dyspnoea threatens. In frac- 
tures with displacement tracheotomy may be followed by attempts at 
replacement of the fragments and their retention in position by means 
of a suitable support. Some advise a thyrotomy and the separation of 
the two halves of the larynx until the fragments have united in good 
position, or, if some have become detached so as to obstruct the larynx, 
to either replace or remove them. Wagner performs thyrotomy, asep- 
ticizes the wound, replaces or removes the fragments of cartilage, and 
packs the cavity of the larynx with iodoform gauze. 
In some cases intubation may be found useful. In fracture of the trachea, a 
rare condition giving a bad prognosis, the symptoms are dyspnoea, extravasation, 
and emphysema, with pain on pressure over the seat of the fracture. For treat- 
ment, complete quietude and, if dyspnoea occur, tracheotomy. 
Burns of the air-passag-es may be caused by the inhalation of 
flame or steam or by the swallowing of hot or caustic liquids. Such 
accidents are quickly followed by acute inflammation, and sometimes 
by considerable swelling. Inflammation may extend to the trachea, 
bronchi, and lungs. 
The early symptoms arc pain, dyspnoea, dysphagia, aphonia, and 
shock. Respiration is rapid and stridulous, the countenance pale and 
anxious, and there is marked restlessness. The symptoms may be mild 
at first, but later severe, especially after the ingestion of caustic liquids. 
Often oedema of the larynx and fatal dyspnoea soon supervene, or, if 
these are escaped, pulmonary complications quickly follow. 
The diagnosis may be made from the history of the case, and, when 
this is unobtainable, from the lesions visible in the buccal cavity. 
Mild cases may recover in a few days. More often death results in 
from one to two days from shock or dyspnoea, or later from laryngitis, FOREIGN BODIES IN THE AIII-PASSA GES. 
161 
bronchitis, and pneumonia. Cicatricial stenosis of the larynx often 
results. 
Treatment.—The inhalation of flame or of steam is always a grave 
accident, complicated as it usually is by other injuries or burns, and by 
physical depression and severe mental shock. Absolute quiet should be 
secured, the strength supported, the digestion regulated, and the patient 
carefully watched for the development of serious respiratory symptoms. 
Many have recommended the administration of calomel. Warm inhala- 
tions, containing a small proportion of opium (tr. opii 3j, boiling water 
Oj), are sometimes successful in relieving irritation and quieting glottic 
spasm and cough. 
When oedema is imminent, if the case is seen early, cracked ice, held 
in the mouth, will often subdue the inflammation and quiet the pain. 
The patient must not be left unwatched for a moment, and if oedema 
occur prompt aid must be afforded by scarification and the subsequent 
application of cocaine. Often urgent dyspnoea develops with startling 
rapidity, requiring instant relief by intubation or tracheotomy. Where 
caustic fluids have been swallowed neutralizing agents should of course 
be resorted to if the case be seen in time. 
Foreign Bodies in the Air-passages. 
Liquids accidentally drawn into the larynx or trachea are usually 
expelled by efforts of coughing. When there is laryngeal insensibility 
it is more serious. The only symptoms may be severe dyspnoea and the 
existence of moist tracheal rales. Death follows at once or is caused 
secondarily by pulmonary inflammation. Spasm of the glottis and even 
death may be caused by the topical application to the larynx of strong 
medicated solutions. 
The entrance of blood or pus into the air-passages may cause rapid 
suffocation. Pus from the pleural cavity, from an abscess of the liver 
or of the mediastinum, may find its way into the air-passages. 
Treatment.—Coughing will usually suffice to expel small quantities 
of fluid. In severe cases, as drowning, the patient should be held with 
his head and shoulders directed downward, his tongue drawn well 
forward, and artificial respiration resorted to. Severe glottic spasm, 
entrance of blood or pus, may make it necessary to do tracheotomy and 
remove the fluid by aspiration. 
Solids.—The entrance of a foreign body into the air-passages must 
always be regarded as one of the most serious of accidents. Introduc- 
tion through an external wound is unusual. 
The variety of bodies which may be inhaled is unlimited. Their size 
is necessarily restricted to the diameter of the glottic aperture. Of 
course upon the size, shape, nature, and seat of lodgement of the object 
will depend largely the degree of harm which it may inflict. 
Foreign bodies may simply lodge in the larynx itself, or may be 
detained in one of the ventricles or wedged in the rima glottidis. They 
may become fastened in the trachea, or descend to its bifurcation, or 
through one of the greater bronchi into one of the more remote bronchial 
tubes. The right bronchus is more apt to be the seat of lodgement than 
the left. 162 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
The symptoms vary somewhat with the size, shape, and position of 
the foreign body. They are sometimes extremely obscure. The primary 
symptoms are—violent spasm of the larynx, choking, cough, and dis- 
tress ; sometimes vomiting occurs, with relaxation of the sphincters. 
Blood may be coughed out immediately after the accident. The dys- 
pnoea may prove speedily fatal, especially when a large body suddenly 
occludes the larynx. The body is sometimes coughed out. Often these 
symptoms subside after a time, but certain signs remain, suggesting its 
presence. The accident may be unrecognized, because the initial dys- 
pnoea and cough may, in some cases, be lacking. The voice may be 
affected. Later symptoms are—modification of the voice, continued 
discomfort, quickened respiration, cough accompanied with expectoration 
of frothy or bloody sputum. If the foreign body is fixed, the symptoms 
may tend to subside; but if it be movable, a change in its position is 
very apt to be accompanied with fresh attacks of the urgent symptoms. 
The general condition of the patient may not suffer, but, on the other 
hand, very rapid loss of strength, appetite, and weight may ensue. 
A foreign body in the trachea may cause severe reflex cough, together 
with certain changes in the current of inspired air heard upon ausculta- 
tion. Lodged in one of the bronchi, unless relieved it will almost cer- 
tainly cause death. Following the exclusion of the air, pneumonia may 
readily develop, or, if the foreign body be particularly irritating in its 
character, abscess or gangrene of the lung may be established. In such 
a case the diagnosis will often be a matter of extreme difficulty unless a 
clear history of the inhalation of the body be obtainable. Auscultation 
will sometimes reveal, at a certain point in the neighborhood of one of 
the larger bronchial tubes, such changes in the air-currents as will indi- 
cate partial occlusion. 
The prognosis, always exceedingly grave, is more serious in the 
child than in the adult. Caustic substances or foreign bodies, such as 
beans, which are capable of swelling, are especially dangerous. The 
long-continued presence of a foreign body in the air-passages may sim- 
ulate phthisis. 
Diagnosis.—The diagnosis, when difficult, depends upon the sudden- 
ness of attack, the absence of fever, and the fact that the patient is 
comparatively well between the attacks of dyspnoea or spasm. Some- 
times the patient is conscious of the movements of the body in the 
trachea. The presence of a foreign body in the oesophagus, causing 
urgent dyspnoea, may generally be demonstrated by means of the 
oesophageal sound. When the foreign body has entered a bronchus the 
passage of air into the lung of that side is, to a greater or less extent, 
prevented. There will, therefore, be a lack of inflation and of respira- 
tory murmur in that lung, without corresponding dulness or other symp- 
tom of acute pulmonary disease. 
Laryngoscopy, aided by local anaesthesia, will often be of great assist- 
ance in demonstrating the position of the foreign body. 
Treatment is often extremely difficult. The statistics of operation, 
although not satisfactory, are slightly in favor of surgical interference. 
In simple cases it is not good practice to excite cough, sneezing, or 
vomiting. Even the inverted position, assisted by percussion upon the 
back, is not recommended, although often effective with children choked PERICHONDRITIS OF THE LARYNX. 
163 
from the ingestion of too large morsels of food, the danger being the 
causing of spasm of the glottis by the impact of the body upon the 
vocal bands. If the foreign body is impacted in the larynx, it may be 
removed through the natural passages, in the case of large objects, by 
means of the linger or a pharyngeal forceps. Smaller bodies should be 
removed, with the aid of the laryngoscope, by means of suitable endo- 
laryngeal instruments, the parts having first been thoroughly cocainized. 
If the object is too large to be removed at once, it may be crushed and 
taken away piecemeal. If it has fallen into the trachea, one of the 
special O’Dwyer tubes may be inserted, in the hope that the object may 
be expelled through it. If it has become impacted in the larynx in 
such a way that it cannot be extracted otherwise, thyrotomy may be 
indicated, or, if the object is small, cricothyrotomy. When the body has 
entered the trachea, tracheotomy is required. The trachea should be 
opened low down, and, unless the body is easily reached and expelled, 
several rings should be divided and the edges of the wound widely 
separated, the patient inverted, and efforts made, by palpating the chest 
or by exciting cough, to cause its expulsion. If necessary, long, slender 
forceps may be used for dislodging it. Sometimes the foreign body will 
remain in situ for several days. 
Perichondritis of the Larynx 
Perichondritis of the larynx is an inflammation of the perichondrium and of the 
cartilages, sometimes followed by caries or necrosis of the latter. It is generally 
secondary, and rarely primary. Among its most common causes are tubercular, 
specific, and cancerous ulceration of the larynx. It may also follow typhoid fever, 
variola, scarlet fever, erysipelas, and pyaemia. It is sometimes occasioned by injury. 
When the perichondritis is due to deep ulceration, necrosis of the cartilage is apt 
to follow through impairment of its nutrition. Separation of the fragment sooner 
or later takes place. In some cases the destructive process is rapid and the seques- 
trum is quickly detached. Deformities, often leading to stenosis of the larynx, and 
sometimes to fistulous openings of it, and ankyloses, particularly of the crico-aryte- 
noid articulations, are some of its results. 
The symptoms are often obscure and not characteristic. Generally 
the pain will be increased by external manipulation of the larynx, and 
dysphagia and dysphonia may be present. Laryngoscopic examination, 
aided by the use of the laryngeal probe, may demonstrate the existence 
of exposed cartilage, and fragments of the latter may be expectorated 
or may hang more or less loosely in the laryngeal cavity. The results 
of direct examination may differ somewhat in accordance with the seat 
of the affection. At the affected point an abscess may develop. 
Diagnosis is made by exclusion and laryngoscopic examination. 
External palpation and inspection are often useful, while the fact that 
the concurrent disease may be attended with this complication will afford 
aid. 
The prognosis will depend upon the cause. Suppurative perichon- 
dritis with necrosis is often very serious, because of immediate accidents 
and ultimate laryngeal stenosis. In tubercular and malignant disease 
the prognosis is bad. In syphilis, however, the prompt and energetic 
use of iodide of potassium, given in frequent doses, is most effective. 
The iodide may be best administered in milk thickened with pepsin, in 
the proportion of ten grains of iodide, one drachm of essence of pepsin, 164 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
and four ounces of milk. This, made into junket, is palatable, nutritious, 
and easily swallowed. Where the symptoms are acute use active meas- 
ures, such as application of cold compresses, sucking of ice, scarification 
of oedematous tissues, and the prompt opening of abscesses. In evacu- 
ating the latter the incision should be made quickly, and the patient 
placed so as to enable him to rapidly expel the discharged pus. For 
urgent dyspnoea perform tracheotomy or insert an O’Dwyer tube. The 
effect of the iodide of potassium will generally render this unnecessary. 
These patients should be watched for a long time, and any tendency to 
deformity of the larynx, if possible, counteracted. 
Stricture of the Larynx, 
other than that due to inflammatory thickening and to new growths, con- 
sists of permanent deformity, the result of previous disease or injury, 
and caused either by displacement of the parts or, as is most commonly 
the case, by the presence of deforming cicatrices. Fractures, perichon- 
dritis, chondritis, ankylosis of the arytenoid articulations and “ web of 
the larynx,” may occasion it, but it is generally due to injury or ulcera- 
tion of the soft tissues which line the larynx, commonly from tertiary 
syphilis, and also to other diseases causing deforming cicatrices, and to 
destruction of the soft parts due to burns. Stenosis of the trachea may 
occur at various parts of this canal from the formation of bands of 
fibrous tissue which distort the tracheal rings. Sometimes the stric- 
tures are multiple. Between them are occasionally seen dilatations of 
the tube. 
The symptoms may be divided into three stages—that of active dis- 
ease, that of stenosis, and, finally, that of suffocation. Again, they 
may at first be mild and progressive, beginning with slight laryngeal 
stridor. This increases, being especially marked on inspiration, and is 
later accompanied by dyspnoea, and often bv change in the quality of the 
voice, which becomes hoarse in stenosis of the larynx or simply weak in 
stenosis of the trachea. Later, dyspnoea increases. Respiration is feeble 
and slow. The attacks of urgent dyspnoea are apt to take place at night, 
and are due to spasm of the glottis. Death may be caused by sudden 
asphyxia or by pulmonary congestion, pneumonia, and oedema. Sudden 
death from syncope will sometimes occur, due to an inhibitory action 
upon the bulbar centres. In stenosis of the trachea the point of greatest 
constriction may sometimes be determined by auscultation, as well as by 
laryngoscopic examination. 
In diagnosing this condition the existence, position, and character of 
the stricture must be established. It has been said that if hoarseness 
has preceded dyspnoea the stenosis is in the larynx ; if dyspnoea pre- 
ceded, it is tracheal. 
A mediastinal tumor, possibly compressing the trachea or bronchi, may be 
revealed by examination of the chest; tumor of the neck may be recognized by 
palpation of this region, and a laryngoscopic examination will establish the differ- 
ential diagnosis between paralyses, tumors of the larynx, and actual stenosis. 
The prognosis is serious, especially in stenosis of the lower part of 
the trachea, which is almost necessarily fatal. 
The treatment consists especially in dilatation of the stenosed TRACHEOTOMY. 
165 
parts. Should this fail, the permanent use of a tracheal cannula is 
always possible. For the actual relief of the stenosis the application 
of intubation has accomplished much. This may be greatly assisted by 
the careful and judicious division of constricting bands of cicatricial 
tissue before the tube is introduced. In the case of a congenital web of 
the larynx the simple wearing of the tube or, if necessary, removal of 
the web before the introduction of the tube, has given brilliant results. 
The patient should be examined at short intervals, the tube occasionally 
removed, and, if necessary, a larger one inserted in its place. This 
treatment should be continued until the necessary enlargement of the 
interior of the larynx is secured. Failing in other means, thyrotomy 
and excision of the offending cicatrices. 
Fistula of the Larynx and Trachea. 
The distinguishing sign of this condition is the passage of air through 
the external opening, together with mucus, and sometimes of pus and 
broken-down tissues. Inspiration is generally normal unless there is 
stenosis of the larynx, but the voice is often modified by the escape 
of the expired air, and in some cases phonation is impossible unless 
attempted when the opening is artificially closed. 
The external orifice of the fistula may be readily detected. Its 
internal opening may sometimes be demonstrated by the aid of the 
laryngoscope. 
These cases are not serious, although sometimes difficult to cure. 
The treatment consists of closing of the fistula, any existing con- 
dition of stenosis of the larynx or trachea first having been removed. 
Small fistulse may be closed by the application of mild caustics or of the 
galvano-cautery, larger ones by vivifying the edges and uniting them 
with sutures. 
As a rule, however, some plastic operation, such as Berger’s or 
Abbe’s, will be required to thoroughly close the opening. 
Tracheotomy is a general name for several operations employed for 
the admission of air to the trachea where the latter, or the approaches 
to it, have become obstructed. These operations are crico-thyroid 
laryngotomy, made through the crico-thyroid membrane; laryngo- 
tracheotomy, through the cricoid cartilage and the first ring of the 
trachea; and the two operations most commonly resorted to, high and 
low tracheotomy, respectively above and below the isthmus of the 
thyroid. 
Before attempting any of these operations it is imperatively neces- 
sary that the anatomical relations of the trachea in connection with them 
should be thoroughly well understood. 
Tracheotomy is easier performed high in the neck than low, for 
the anterior jugular veins are smaller above and transverse branches 
are rare; the muscles are somewhat separated above, while below they 
are in contact; the great vessels and the inferior thyroid veins are 
avoided. Here, too, the trachea is nearer the surface and more readily 
held in position. The lower the incision in the trachea, the greater the 
Tracheotomy. 166 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
danger of sepsis and of broncho-pneumonia. On the other hand, par- 
ticularly in the adult, the necessities of the case will sometimes demand 
a low operation. 
Fig. 72. 
Fig. 73. 
Trousseau’s tracheal dilator. 
Silver tracheotomy-tube. 
The Tube.—The tube should be selected with careful reference to 
the case in hand. The one now in common use goes under the name of 
Trousseau. The thickness of the tissues covering the trachea varies 
greatly in different individuals. Durham has therefore devised a can- 
nula the length of which from the neck-plate can be regulated by means 
of a screw-collar. The cannula itself is straight until within a short 
distance of its distal end. Certain defects of the Durham cannula have 
been avoided in the tube devised by Keen. 
Konig’s tube, designed for the relief of stenosis occurring low down 
in the trachea, is about four and a half inches long. Abbe suggests an 
improvised cannula for deep tracheal obstruction, made by inserting a 
piece of soft-rubber tubing into the trachea and transfixing its proximal 
end with a safety-pin. 
Many different devices have been made for the performance of rapid 
tracheotomy. They are practically never used. 
Tracheal tubes are composed of silver, aluminum, hard rubber, soft rubber, and 
celluloid. As a rule, metal tubes are preferred. The bard rubber-cannula, how- 
ever, is very useful when the tube is to be worn but for short time, and is more 
comfortable, for several reasons, than metal. 
The indication for tracheotomy is the presence of an occlusion of the normal 
opening of the larynx from acute or chronic causes, which causes dyspnoea sufficient 
to endanger life, which cannot be overcome by other means. The operation in 
itself is usually not dangerous, nor is it likely to cause serious complications to the 
disease for which it is employed. Its early performance where indicated, there- 
fore, should, wherever possible, be advised. 
When practicable, chloroform anaesthesia should be employed before this ope- 
ration. Ether causes nausea, vomiting, and embarrassing reflex movements of the 
larynx. The hypodermic injection of cocaine, although recommended by some, 
in the experience of the writer has not always succeeded in allaying the pain. 
In tracheotomizing children, especially in diphtheria, chloroform is 
apt to be contraindicated. Its administration may cause rapid increase 
of dyspncea, and greatly complicate an operation which under the condi- 
tions of cyanosis present is not likely to create suffering. 
The operation of tracheotomy is generally performed as follows, under 
chloroform unless contraindicated by dyspnoea and laryngeal irritation, TRACHEOTOMY. 
167 
and with proper antiseptic precautions : The patient is placed upon his 
back near the right side of the operating-table. A suitable firm sup- 
port is placed under the neck and shoulders, and the head allowed to 
bend backward in extreme extension. In this position the anterior 
Fig. 74. 
Position of patient for tracheotomy. 
structures of the neck are rendered tense, the trachea steadied, drawn 
as far upward as possible, and brought somewhat nearer to the surface 
of the neck, and the superficial veins somewhat emptied. To the assist- 
ant who administers the anaesthetic is also given the duty of holding 
the patient’s head steady and of keeping the chin exactly in the median 
line. The latter is very important to the surgeon, the accuracy of whose 
incisions is likely to be determined by the careful observance of it. At 
least one other assistant is desirable to attend to the bleeding and super- 
intend the instruments and the tube. 
Before making the first incision the operator should clearly define the 
position of the thyroid and cricoid cartilages and of the median line. 
With a sharp scalpel, held between the thumb and finger, an incision 
should be made through the integument from an inch to an inch and a 
half long, and precisely in the median line, downward from the level of 
the upper border of the cricoid, the parts on each side of the cut being 
steadied meanwhile by the thumb and fingers of the left hand. The 
movements of the thorax in respiration make it impossible to support 
the right hand upon the chest during the performance of the operation. 
Next, in the same way as above, the subcutaneous fat and the anterior 
cervical fascia are divided. By successive incisions, aided by the director 
and the handle of the scalpel, the sterno-hyoid and the sterno-thyroid 
muscles are reached, and the space between them opened, and the fascia 
covering the trachea demonstrated. Then, keeping strictly in the median 
line, the deep fascia is divided and the trachea laid bare. For the divis- 
ion of the fascia the help of a director is valuable. Any veins encoun- 
tered at this point in the operation should be pushed aside with the 
handle of the scalpel. The isthmus of the thyroid must be similarly 
pushed downward, and, if necessary, held out of the way with a small 
blunt retractor. The tracheal rings may now be felt with the finger, the 
fact that the trachea is actually laid bare assured, the exact situation of 
the cricoid noted, and the precise position of the intended opening into 168 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
the trachea located. A silk suture passed through the trachea on either 
side the opening, and then through the skin, tied, and the ends left long, 
makes a most serviceable retractor and guide should the tube require 
replacing. 
For the next division of the operation the following should be in 
readiness and at hand—namely: A sharp scalpel or tenotomy knife, 
the tenaculum, the tracheal dilator, a damp towel, and, finally, the tube, 
properly oiled, to which a tape of length sufficient to twice surround the 
neck of the patient should have been passed into one of the eyelets at 
the side of the neck-guard. Everything being in order and if possible 
all bleeding controlled, a small sharp tenaculum is passed into the cricoid 
cartilage in the middle line and held by the assistant, who stands behind 
the patient’s head. His duty is to keep the tenaculum in the median 
line, and with it to draw the cricoid forward and keep the trachea steady 
and tense. The up-and-down movement of the larynx in respiration 
will make it necessary to not hold the hook too rigidly. Having decided 
which rings to divide, the operator introduces the scalpel into the wound, 
the edge of the knife being directed upward, and, guided by the left fore 
fiuger, inserts the knife, exactly in the median line, into the lowest of 
the two or three selected rings (usually the first three of the trachea) and 
cuts directly upward toward the tenaculum. The latter is still held in 
position, and the knife not removed from the tracheal incision, but 
turned slightly upon its vertical axis, so as to separate the sides of the 
opening and admit the tracheal dilator, which is next inserted, and the 
opening sufficiently dilated to enable the tracheal tube to be passed. This 
should be done as easily and expeditiously as possible, and the tube at 
once secured in position by passing one end of the tape around the 
patient’s neck, through the unoccupied eyelet of the neck-plate of the 
tube, and back around the neck, to be tied to its fellow. 
The presence of the tenaculum in the cricoid excites such urgent 
reflexes of the larynx that until the trachea is opened the patient in 
many instances cannot breathe. The effect of the sudden entrance of 
the air is to excite such expulsive efforts of cough that the mucus, blood, 
or membrane which may be in the trachea are projected forth with great 
violence. For the protection of the operator as the trachea is being 
dilated, an assistant should hold a damp towel a short distance above 
the wound. 
In no case should the tube be introduced without previous separation of the 
edges of the tracheal incision. Disregard of this rule will defeat the attempt at 
introduction, and may result in serious injury to the parts, particularly where the 
rings of the trachea have become partly ossified. Pressure against the incision 
only forces its edges the more firmly together, while undue force may either frac- 
ture the cartilages or, from the slipping of the tube, force it downward through 
the tissues on the side of the trachea, thus inflicting damage. In such cases, 
where the tube must be worn habitually, it is better not to rely upon a simple 
vertical incision of the trachea, but to actually exsect a circular portion of the 
anterior wall equal in size to the diameter of the required cannula. The result is 
more comfortable to the patient, and enables the cannula to be inserted more 
easily. When the tube is in place the tenaculum may be removed, and the wound 
below the tube brought together by one, two, or three sutures. A piece of lint 
properly shaped to cover and protect the wound is smeared with some antiseptic 
ointment and placed under the shield of the cannula. 
Subhyoid pharyngotomy lias, oil rare occasions, been employed in LARYNGOTOMY. 
169 
the removal of a foreign body or of a new growth situated in the upper 
opening of the larynx, and particularly in the neighborhood of, or in 
connection with, the epiglottis. It is seldom used, since the access to 
the larynx accorded by it is very small. In operating, a transverse 
incision is made through the thyro-hyoid membrane near the inferior 
border of the hyoid bone and parallel with it. By means of this 
incision the epiglottis is exposed, and, where possible, drawn through 
the wound. In patients in whom the neck is thick this is not easy. 
The growth is then removed, bleeding checked, and the wound closed. 
There are no important vessels in the way, and prompt healing should 
result. The statistics of the operation are not good, as danger from 
sepsis is considerable. 
Infrathyroid laryngotomy has been performed for the removal of 
subglottic growths. In operating, the laryngotomy should be made sev- 
eral days before the attempted extirpation of the growths, in order to 
accustom the parts to the presence of the tube and thus reduce the irri- 
tation for the chief operation. In performing the latter the crico- 
thyroid space is well opened up and the cartilages separated as widely 
as possible. Space is then given for the removal of the growth, which 
should be effected by the aid of proper laryngeal instruments and 
methods, the cavity being sufficiently illuminated meanwhile to admit 
of thorough and accurate work. In readjusting the parts it is safer to 
allow a cannula to remain until the danger of obstructive inflammation 
of the larynx shall have subsided. 
Laryngotomy. 
Laryngotomy, performed by opening the larynx through the crico- 
thyroid membrane, is sometimes employed in place of tracheotomy. 
The operation is not as difficult as the latter, and may be performed 
more rapidly. It is not applicable to children, on account of the small 
size of tiie crico-thyroid space. While it may answer for emergencies, 
it is not desirable where the tube must be worn for any length of time. 
The only important vessels to be encountered are the crico-thyroid 
arteries, which cross this space and are usually of small size. They 
may, however, be large enough to give rise to serious hemorrhage. 
The after-management should be conducted with scrupulous care. For the 
first few days at least the patient should be under the supervision of an attendant 
thoroughly competent to provide the special assistance necessary in such cases. 
The tapes must be kept in order, and the tube frequently cleansed of secretion by 
withdrawing the inner cannula and cleaning it. The latter should be returned as 
•quickly as possible. It should be thoroughly disinfected and well oiled upon its 
inner as well as upon its outer surface before being again introduced. In the 
matter of feeding assistance will sometimes be gained by the use of the oesophageal 
tube, especially in children. 
The operation of thyrotomy consists in the complete division of the 
thyroid cartilage in the median line. It is employed in gaining access 
to the larynx for the removal of new growths or for other obstructive 
conditions, such as impacted foreign bodies, irremediable cicatricial 
bands, or the like. As it is likely to cause impairment of the voice, it 
should not be undertaken unless clearly indicated through failure of 
endolaryngeal methods to attain the desired end. On the other hand, 170 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
in certain serious conditions it affords the best possible opportunity for 
the thorough accomplishment of the purpose for which it is performed, 
and in good hands has been attended with excellent results. 
A preliminary laryngotomy or tracheotomy is required, and should 
be performed a number of days before the main operation. The selec- 
tion of the point at which the tube is to be inserted should depend upon 
the situation of the growth and the probable length of time that the tube 
will have to be worn. Should extensive bleeding be expected, a tampon- 
cannula must be used. In performing the thvrotomy the incision already 
made is prolonged upward from the median line and the tissues divided 
down to the cartilage, the cut extending upward to some point in the 
thyro-hyoid space. In dividing the thyroid cartilage it is customary to 
carry a perfectly true incision accurately in the median line, the crico- 
thyroid membranes being also divided as far as is necessary. The 
division of the cartilage should be effected from above downward and 
from without inward, and may be accomplished by means of a small but 
strong knife in patients in whom the thyroid has not begun to calcify. 
In case the latter condition is present, brilliant results have been gained 
by the electric saw, as recommended by Wagner. A strong scissors may 
also be used for the purpose. The dissection having been accomplished, 
the wings of the thyroid are drawn apart by means of two small sharp 
retractors or by means of threads passed through them, and the interior 
of the larynx is thus exposed. In closing the wound the two halves of 
the thyroid are united by two or three sutures of fine silver wire and the 
superficial wound closed. 
The subsequent treatment, in the main, will be such as is carried out 
after tracheotomy, special indications being met and the interior of the 
larynx meanwhile not being neglected. 
When thyrotomy has been performed for the removal of a new 
growth, however, and considerable injury done to the soft part of the 
interior of the larynx, much better results will be obtained by keeping 
the edges of the thyroid apart until the healing of the deeper structures 
shall have been completed. Some of the best operators remove the tube 
at once after the completion of the operation, and allow the patient to 
breathe through the thyroid opening. In the removal of a malignant 
new growth the necessity for the thorough illumination of the larynx 
will be apparent. For this purpose a forehead reflector should be pro- 
vided, and, if possible, a small Edison incandescent lamp of two or 
three candle-power. The application of cocaine to that part of the 
larynx which is occupied by the growth will render it easier to distin- 
guish the diseased areas and lessen the amount of bleeding. In the 
after-treatment the larynx is kept open, the surface of the wound dusted 
two or three times a day with iodoform powder or iodoform and boracic 
acid, equal parts; the patient’s head kept low, and the external wound 
covered with iodoform gauze. The patient may be able to swallow 
liquid food at an early date by keeping the head low during the attempt. 
Thyrotomy as employed for the removal of malignant disease of the 
larynx was formerly singularly unsuccessful. In late years, however, 
the results obtained by it have been increasingly better, and at the present 
time it promises to rank as one of our most valuable aids in such con- 
ditions. INTUBATION OF THE LARYNX. 
171 
In performing operations of this class it is sometimes necessary to 
prevent blood from entering the trachea, which may be accomplished 
either by packing the latter with sponge or gauze, or by means of a 
device know as the tampon-cannula. This instrument is a tracheotomy- 
tube around the outside of which is attached a dilatable sac of India- 
rubber, which, being inflated when the apparatus is in position, effect- 
ually occludes the trachea above the opening of the tube. Excellent 
modifications of the original Trendelenberg cannula have been made 
by Roswell Park, Hahn, Gerster, and others. 
Intubation of the Larynx. 
Intubation of the larynx, as perfected and established by Dr. Joseph 
O’Dwyer, is a most valuable addition to the surgery of this depart- 
ment. 
Intubation Instruments.—A set of instruments for children under 
the age of puberty consists of six tubes, of different sizes and varying in 
length from one and a half to two and a half inches; an introducer, an 
Fig. 75. 
O’Dwyer’s laryngeal tube and introducer. 
extractor, a mouth-gag, and scale of years. Each tube is provided with 
a separate obturator for the purpose of attaching it to the introducer. 
The numbers of the scale represent years and indicate approximately 
the ages for which the corresponding tubes are suitable. The female 
larynx in children as well as in adults is smaller than in the male. 
In measuring the tubes the heads are of course included. 
Having selected the tube, a strong thread is passed through the 
small eyelet at its head, and the ends tied together. Braided silk 
is the best, and the piece 
should be sufficiently long to 
reach the stomach and still 
leave a portion protruding 
from the mouth. The obtu- 
rator is then screwed firmly 
up on the introducer to prevent 
the tube from rotating while 
being inserted, and fixed so that 
the long diameter of the tube 
when applied and ready for use is in a line with the handle of the 
introducing instrument. 
Fig. 76. 
Mouth-gag. 172 
DISEASES AND INJURIES OE THE RESPIRATORY ORGANS. 
Indications for Intubation.—The indications for intubation in chil- 
dren are the same as for tracheotomy. There is no reason why one 
Fig. 77. 
Extractor. 
should be performed earlier than the other. The beginning of the suf- 
focative stage is the proper time to interfere. Marked cyanosis is too 
late a symptom to wait for, and, besides, fatal obstruction may exist in 
the glottis with extreme pallor of the surface. 
The method of intubation applies to any obstruction of the larynx 
not due to a foreign body. 
Method of Operating.—The person who holds the child should be 
Fig. 78. 
Intubation of the larynx. 
seated on a solid chair with a low back, and the patient placed as repre- 
sented in Fig. 78. Fastening the hands in front of the chest, or thick 
garments in the same location, render it more difficult to depress the 
handle of the introducer sufficiently to carry the tube over the dorsum 
of the tongue. INTUBA TION OF THE LARYNX. 
173 
The gag is then inserted well back, behind or between the teeth in 
the left angle of the mouth, and the jaws very carefully separated. In 
children who have not at least one bicuspid on the left side, the finger 
shonld be used instead of the gag. An assistant holds the head firmly, 
at the same time slightly elevating the chin. The operator stands in 
front of the patient, holding the introducer lightly between the thumb 
and fingers of the right hand, the thumb resting on the upper surface 
of the handle just behind the knob that serves to detach the tube, and 
the index finger in front of the trigger support underneath. Held in 
this manner, it is impossible to use undesirable force. 
The index finger of the left hand is carried well down in the pharynx 
or beginning of the oesophagus, and then brought forward in the median 
line, raising and fixing the epiglottis, while the tube is guided along 
beside it into the larynx. It' any difficulty is experienced in locating 
the epiglottis, it is better to search for the cavity of the larynx, into 
which the tip of the finger readily enters, and which cannot be mistaken 
for anything else. Once in this cavity, the epiglottis must be in front 
of the finger. The latter is then raised and pressed toward the 
patient’s right to leave room for the tube to pass beside it. The distal 
extremity of the tube should be kept in contact with the finger, and 
even directing it a little obliquely toward the right side of the larynx is 
necessary to get inside the left aryteno-epiglottic fold, especially in very 
young children. The handle of the introducer is held close to the 
patient’s chest in the beginning of the operation, and rapidly raised as 
soon as the lower end of the tube has passed behind the epiglottis, other- 
wise it will slip over the larynx into the oesophagus. 
When inserted the cannula is detached by pressing forward the button on the 
upper surface of the handle of the introducer with the thumb, and in removing 
the obturator the movements required for insertion are reversed. To prevent the 
tube from being also withdrawn, the finger must be kept in contact with its shoul- 
der either on the side or posteriorly, and the tube should be carried well down in 
the larynx before it is detached. 
The gag is removed as soon as the tube is in place, but the string is allowed to 
remain long enough to be certain that the dyspnoea is relieved and that no loose 
membrane exists in the lower portion of the trachea. 
In withdrawing the tube the child is held as in introducing it, and the extractor 
is guided along the side of the finger, which is brought in contact with the head of 
the cannula, and then pressed toward the patient’s right, in order to uncover the 
aperture and allow the instrument to enter in a straight line. No attempt at 
extraction should be made until the head of the tube is felt. 
Introduction of the tube must be accomplished quickly, the whole performance 
not occupying more than ten seconds. 
To place a tube in the larynx of a struggling, choking child in the brief space 
of time that is compatible with safety is a difficult thing to do, and should not be 
attempted, except in case of emergency, without previous practice on the cadaver 
or on the larynx of an animal removed and placed in a suitable position. 
The proper time for removing the tube from the larynx will depend on the 
age of the patient, the character of the disease, whether of slow or rapid develop- 
ment, and the progress of the case. In diphtheria the younger the patient, as a 
rule, the longer the tube will be required. In children under two years of age it 
is better to leave it in seven days. When the above disease has developed slowly, 
and has therefore run a greater part of its course before calling for operative inter- 
ference, the tube can be dispensed with earlier—sometimes as soon as the second 
or third day. If the case cannot be seen within a reasonable time, it is safer, if 
progressing favorably, to leave the tube in position for seven or eight days, and 
the exceptions are few in which it will be necessary to reinsert it after this time,. 174 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
The tube should always be removed on the recurrence of severe dyspnoea, 
because it is sometimes impossible to ascertain with certainty whether it be par- 
tially obstructed or not. The best evidence to the contrary is a good respiratory 
murmur or numerous rales over the lower posterior portion of the lungs. Even 
under these circumstances the lumen of the tube may have been encroached upon. 
In cases refusing nourishment after intubation it is useless to remove the tube for 
the purpose of feeding, unless it has been in long enough to give some reasonable 
hope that its further use will not be necessary, as it is difficult to convince children 
for some time that they can swallow any better than before. If no dyspnoea recur 
in half an hour after the extraction of the tube, it is safe to leave the patient, if 
not at too great a distance to be reached within two or three hours. 
Accidents and Dangers of Intubation.—The most serious of the 
accidents incident to this operation is apnoea from prolonged attempts 
in unskilful hands to introduce the tube. Ten seconds is the longest 
time that should be occupied in each attempt if the child be suffering 
from urgent dyspnoea at the time. If the finger be then removed from 
the mouth and the patient be given a chance to get his breath, many 
attempts to properly place the tube can be made without danger, although 
the expert seldom requires more than five seconds to complete the opera- 
tion, except in difficult eases. In these, if necessary, an anaesthetic 
may be used. 
If the tube have once passed on the outside of the larynx, and this 
is recognized before it is detached from the obturator, it is useless to 
try to rectify the position without first depressing the handle of the 
introducer, as in the beginning of the operation. 
The tube may be passed into one of the laryngeal ventricles and a 
false passage made if care be not taken to pass it in the median line. If 
the patient’s head be thrown too far back, the tube may also be arrested 
by coming in contact with the anterior wall of the larynx or trachea. 
Pushing down membrane before the tube is the most serious of the 
unavoidable accidents attending this operation. In several such cases 
removal of the tube has been followed by expulsion of complete casts 
of the trachea, although in none of these cases was the dyspnoea relieved 
by the ejection of the membranes, and the immediate reintroduction of 
the tube was necessary because the obstruction was in the glottis. 
Where the child is inclined to injure the string with his teeth, the 
difficulty may be overcome by passing the thread between two of the 
double teeth. When this plan cannot be adopted, a smaller tube than 
the one suitable for the age should be used, which seldom fails to be 
rejected if obstructed. 
In the event of sudden asphyxia the nurse should hold the child 
head downward, at the same time shaking it or slapping it vigorously 
upon the chest. Serious obstruction does not seem to result from loose 
membrane above the tube, but extreme tumefaction of the epiglottis 
and aryteno-cpiglottic folds does in rare cases give rise to dangerous 
constriction at this point, necessitating tracheotomy. 
The tube is more liable to be expelled in the act of vomiting than by coughing. 
The larynx may be injured in attempting to remove the tube if the extractor be 
passed down beside instead of into the opening. It is important, therefore, to 
remember that no force whatever is required to remove the tube, and that any 
resistance to the withdrawal of the extractor proves that it is caught in the tissues 
on the outside. 
In feeding after intubation the entrance of food into the trachea is TUMORS OF THE LARYNX AND TRACHEA. 
175 
almost sure to be fatal. Liquid or semi-solid food may be given through 
an oesophageal tube or by enema. The best method is to allow the child 
to swallow it while his head is depressed and a little to one side. 
Intubation may be employed to relieve dyspnoea or as a curative agent to effect 
dilatation in deformity of the interior of the larynx. In the adult it is applicable 
in a large variety of conditions of laryngeal stenosis, both acute and chronic, 
among which may be mentioned obstruction to the larynx or oedema glottidis from 
any cause; injury to the larynx from fracture, incised wounds, or internal violence, 
as from attempted endolaryngeal operation, foreign body, or the like. The chronic 
conditions in which it is indicated are such cases of stricture as may be amenable 
to treatment by the division of cicatricial bands and systematic dilatation. These 
include cicatricial contractions resulting from syphilis and other diseases attended 
with laryngeal ulceration, and from traumatisms and chronic thickening of the 
soft parts, in which the subglottic variety may sometimes be included. It is also 
useful in some cases of laryngeal neoplasm, in laryngeal paralysis threatening 
asphyxia, and in advanced tubercular laryngitis with obstruction. It may also be 
useful in fracture and other injuries of the laryngeal cartilages. 
The insertion of the tube is less difficult in the adult than in the child. It 
should be done, if possible, with the aid of the laryngoscopic mirror, although this 
is not absolutely necessary. 
In passing the tube the larynx should first be anaesthetized with cocaine. The 
patient should be seated as for the ordinary laryngoscopic examination, and the 
tube, aided by the mirror, should be introduced as in the infant, excepting that 
the finger of the operator is not used as a guide. Instead of this, as is customary 
in the passage of any endolaryngeal instrument, the aid of the patient is depended 
upon to open the larynx, either by the act of phonation or deep inspiration. The 
use of a mouth-gag in the adult is not required. Intubation in suitable chronic 
cases has practically superseded all older methods of dilatation. While the larynx 
tolerates the presence of the tube with great readiness, too long retention may 
injure it, and is not recommended. Such a case should of course be watched, and 
the tube removed and reinserted as often as required by cleanliness, the condition 
of the parts, or the necessity for more active dilatation through the insertion of a 
tube of larger diameter. 
Tumors of the Larynx and Trachea. 
New growths of the larynx may affect it primarily or may extend to 
it from neighboring parts. They may be either benign or malignant. 
Distinction between the two varieties is sometimes extremely difficult. 
The so-called tubercular specific tumors which are occasionally seen in 
the larynx are not properly to be included in this class of affections, and 
should be considered elsewhere. 
The etiology of benign growths of the larynx is practically un- 
known. Although more common between thirty and fifty, they may be 
observed at any age, and one form of growth, papilloma of the larynx, 
may be congenital. 
These tumors are more common in men than in women, and their 
most frequent location is upon the vocal bands. 
Subglottic tumors are comparatively rare. Intraglottic growths 
usually spring from the free border of the anterior part of the vocal 
bands—those above the glottis from the epiglottis and from the aryteno- 
epiglottic folds, the subglottic from the inferior surface of the vocal 
bands. The benign tumors which may occur in the larynx, somewhat 
in order of frequency, are—1. Papillomata; 2. Fibromata; 3. Cystic; 
4. Angeiomata ; 5. Adenomata ; 6. Myxomata ; 7. Lipomata; 8. Chon- 
dromata. Although these growths occur in considerable variety, there 
are but few that are seen with any degree of frequency. 176 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
The symptoms of intralaryngeal growth will depend upon the loca- 
tion, the size, and the shape of the tumor, whether it is pedunculated or 
not, and, to some extent, upon the age and characteristics of the patient. 
The most commonly observed symptom is the alteration in the quality 
of the voice. This, at first hardly perceptible, becomes more and more 
marked, until finally complete aphonia may result. Especially is this 
the case with new growths situated upon the vocal bands. The change 
in position of a pedunculated growth may cause sudden and marked 
alteration in the symptoms, while a vascular growth, particularly in the 
early stages of its development, may demonstrate its presence or not in 
accordance with the state of activity of its circulation. Dyspnoea, gen- 
erally wanting in the adult unless the growth should have attained con- 
siderable size, in the infant is commonly present and may be urgent. 
It is generally more severe at night than during the day, is accompanied 
by stridor, and is due to obstruction by the growth, the inflammatory 
conditions excited by it, and sometimes by the attendant spasm of the 
glottis. It may be so simple as to pass unnoticed, or so severe as to 
cause death from asphyxia, varying with the location of the growth. 
Cough in the adult is usually not marked, and is distinctly laryngeal in 
character. In the child it is a frequent symptom, and often severe. It 
is spasmodic, and is sometimes accompanied with haemoptysis. There is 
rarely dysphagia or pain. 
The only satisfactory means for studying these growths is by the use 
of the laryngoscope. The expectoration will seldom give evidence of 
their existence. 
Their progress is usually slow, varying with the nature of the 
growth. Papillomata sometimes increase rapidly, especially where a 
growth has been irritated by attempts at removal, by intercurrent acute 
affections, or by over-use of the voice. 
Their duration is, of course, variable, and they may recur after 
removal, especially papilloma and cyst. 
The prognosis depends upon the nature of the new growth and upon 
the age and general condition of the patient. It is far more serious in 
the infant, on account of the difficulty of endolaryngeal operation, and 
also because in the child the papillomatous variety is the most common. 
Of all the varieties of growth, so-called diffuse papilloma is by far the 
most serious, on account of the difficulty in differentiating it from epi- 
thelioma. Recurrence is frequent in this, contrary to what is true in the 
case of other benign growths. 
Tr eatment.—Laryngeal growths are probably less common now 
than formerly, by reason of the early and effective treatment of the 
subacute and chronic affections of the upper air-passages, and especially 
those of the nose. As to the actual treatment to be pursued in a given 
case, everything will depend upon the age and condition of the patient, 
the location, size, and shape of the growth, and, most important of all, 
upon its histological character. 
The possibilities of the treatment of papilloma may be considered as 
follows : In infants, particularly where the growth is interfering with 
respiration, it should generally be removed as speedily as possible. 
Thyrotomy in many cases has given excellent results. MALIGNANT GROWTHS OF THE LARYNX. 
177 
Danger from the growth of granulations may be avoided by the 
wearing of a tracheal cannula. 
Whether a supposed papilloma is in reality a malignant growth or 
not, it should never be unduly irritated. If the tumor be pedunculated, 
circumscribed, and located conveniently, there are few objections to its 
removal by endolaryngeal operation. When, on the other hand, it is 
sessile, difficult to reach, or multiple, such attempts may give imperfect 
results or be followed by quick recurrence, and other methods may be 
indicated. Of these the one attended with the best results in the experi- 
ence of the writer is the frequent daily application to the interior of the 
larynx of a spray of strong alcohol. Under this, persistently continued, 
growths of considerable size have entirely disappeared. Local rest is 
imperative. Complete cure has more than once followed tracheotomy. 
In the employment of the endolaryngeal method the larynx is first 
cocainized, and while its interior is being demonstrated by the laryngo- 
Fig. 79. 
Dundas Grant’s laryngeal forceps. 
scope a suitable instrument is introduced into it, and the growth, or a 
fragment of it, seized and removed. Many different methods and 
instruments are used for this purpose. Among them may be mentioned 
evulsion by means of forceps (Mackenzie’s, Grant’s, Shroetter’s, Krause’s); 
crushing or “grattage” (Voltolini), by which such parts of the growth 
as are not removed are so injured that they either slough or are destroyed 
by the resulting inflammation ; incision with laryngeal knife or scissors; 
excision by means of specially constructed laryngeal instruments or by 
the cold-wire snare or the galvano-eaustic loop; cauterization by means 
of the galvano-cautery or chemical caustics, such as chromic acid, nitrate 
of silver, and chloride of zinc. 
Malignant Growths of the Larynx 
Malignant disease of the larynx may be intrinsic or extrinsic, pri- 
mary or secondary. It may be sarcomatous or carcinomatous. Epithe- 
lioma is by far the most common. 
Laryngeal cancer most frequently attacks men at middle life. It may 
occur, however, in the young. Local irritations seem to favor its pro- 
duction. In its earlier stages it is generally unilateral. 
Sarcoma commonly originates either from the true or from the false 
vocal bands, although it may spring from almost any part. The tumor 178 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
is usually rounded, and single or somewhat lobulated. Tts surface may 
be either smooth or somewhat papillary or rugose. The color is gen- 
erally red ; sometimes, however, it is grayish-yellow, and in other cases 
of a darker color than the surrounding membrane. Often, especially 
when ulceration has taken place, it may be difficult to distinguish it from 
papilloma, and the diagnosis can only be established by microscopical 
examination. When the disease is making rapid progress and destroy- 
ing and infiltrating the structures in its neighborhood, it is difficult to dis- 
tinguish it from carcinoma. It is commonly of the spindle-celled variety. 
The favorite points of departure for epithelioma of the larynx are the 
ventricular bands. It may arise, however, from one of the vocal bands, 
the epiglottis, the aryteno-epiglottic folds, or, indeed, from any part of 
the larynx. As the disease extends it becomes impossible to identify the 
point of origin. In general, it is apt to originate from parts which are 
subject to a certain amount of irritation. The appearance of the growth 
in its first stages is variable. It may occur as a small papillary tumor, 
as a rounded well-defined swelling, or as a diffused infiltration. The 
first variety is often impossible to differentiate from true papilloma. A 
valuable early diagnostic sign is the general infiltration of the muscles 
in the neighborhood of the growth, resulting in a marked corresponding 
loss of motion, as also is the tendency of epithelioma to advance from 
the middle of the larynx backward: in papilloma the opposite is true. 
The microscopical demonstration of epithelioma will of course estab- 
lish the diagnosis. Failure to find it, however, does not by any means 
exclude it. 
In the later stages diagnosis is less difficult. The surface becomes 
ulcerated, covered with unhealthy granulations, and bathed in fetid 
pus; the surrounding mucous membrane is inflamed, and sometimes 
there is considerable submucous oedema. The cartilages are attacked, 
and sometimes those in its neighborhood become ossified, especially the 
upper tracheal rings in extensive epithelioma of the lower part of the 
larynx. Deformities of the exterior contour of the larynx appear, and 
as the disease progresses the neighboring parts outside the larynx be- 
come involved in a process of general destruction. 
The TREATMENT OF MALIGNANT TUMORS OF THE LARYNX may be 
either palliative or curative. The palliative treatment may be either 
therapeutic or surgical. For the former, various topical applications 
may be made to the affected parts by means of solutions, sprays, 
powders, or vapors. Solutions are generally used in the form of 
atomized sprays, and are employed for purposes of cleansing or disin- 
fection, to subdue pain, and to retard or overcome the progress of the 
growth: they may consist of antiseptics (Dobell’s solution, listerine, 
boracic acid, and the like), anodynes (cocaine or morphine), or caustic 
medicaments. The comfort of the patient may be enhanced and much 
local and general irritation prevented by keeping the parts strictly 
cleansed and by great care in the matter of feeding. By the surgical 
palliative treatment dyspnoea may be relieved by intubation or trache- 
otomy, and obstructing fragments of the growth may be removed. 
The curative treatment may be divided into three classes—namely, 
endolaryngeal operation, laryngo-fissure or thyrotomy, and laryngectomy 
or extirpation of the larynx. LAR YNGECTOMY. 
179 
Tumors of the trachea may be benign or malignant. The benign 
growths, often referred to as polyps, are generally either fibromata or 
papillomata. Submucous cysts, multiple enchondromata, and osteomata 
have been observed. In addition to these may be mentioned the 
various kinds of growth composed of granulation-tissue which develop 
after tracheotomy either during the time the cannula is in position or, 
as occasionally happens, in the cicatrix of the wound. The dyspnoea 
which they cause sometimes necessitates reopening the trachea for their 
removal and the reintroduction of the cannula. 
The treatment consists in the removal of the growths. This may 
occasionally be done through the natural passages, as described by 
Jarvis, or with the Grant forceps in cases where the growth occurs 
in the vicinity of the glottic aperture ; otherwise, tracheotomy and 
removal by suitable means. In operating, the head of the patient 
should be low, in order that the blood may not gravitate into the 
bronchi. 
Laryngectomy. 
In total excision the patient lies on the back with a pillow under the 
shoulders, the head being somewhat low. A preliminary tracheotomy is 
often performed and a tampon-cannula inserted. An incision is made in 
the median line from the hyoid bone to a point a little below the cricoid 
cartilage, and a transverse incision over the hyoid bone meets this at its 
upper end. On exposing the larynx the sterno-hyoid muscles are drawn 
to one side and severed close to their insertion. The soft parts are 
bluntly dissected from the larynx. Vessels are ligated as encountered. 
After the sides of the larynx become free the inferior constrictor of the 
pharynx is cut close to its insertion into the thyroid cartilage. The 
trachea is next cut across just below the cricoid, and drawn forward, 
while its lumen is well packed with sponges or iodoform gauze, after 
the insertion of a trachea tube of proper size and form. Where 
possible, preservation of the lower half of the cricoid will aid in the 
adaptation of the artificial larynx. The larynx is dissected from the 
deeper parts until the upper corners of the thyroid are freed. Finally, 
the thyro-hyoid membrane is cut across and the larynx removed. The 
epiglottis is removed or left in place according to its condition. If it is 
desirable to see the inside of the larynx before removing it, the thyroid 
can be split down the middle and the sides held apart, while the upper 
end of the trachea is packed with sponge or gauze. The organ can 
then be removed piecemeal. 
The partial operation is usually performed by splitting the thyroid 
down the middle, packing the upper end of the trachea, and then 
removing as much of the larynx as is desirable. 
After the operation the upper end of the trachea is packed firmly 
with gauze to prevent blood and saliva from flowing into it, and the 
rest of the wound stuffed lightly witli an antiseptic gauze. Foreign 
material may be prevented from entering the lungs by elevating the 
foot of the bed. Nutritive enemata are given for the first forty-eight 
hours; then a stomach-tube may be passed through the wound into the 
oesophagus and gastric feeding begun. The packing is removed from 180 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
the wound as often as necessary, and the parts washed with a weak 
antiseptic solution. 
If suited to the case, an artificial larynx may ultimately be inserted. 
The simplest and best of these is the one devised by Bond of London. 
In a modification, practised with brilliant success by Cohen, the 
whole larynx is removed and the free end of the trachea fastened to 
the outside of the cervical wound. This secures complete removal of 
the growth, and subjects the patient to the minimum of risk of impair- 
ment of special function and usefulness of the part, of discomfort, and 
of outward deformity. The chief danger, aside from unskilful technique 
and accident occurring during operation, is that of septic infection or of 
septic pneumonia. 
Injuries to the Epiglottis. 
In a wound of the epiglottis the question is whether the injury can 
be spontaneously repaired or whether the removal of the lacerated or 
diseased portion may be desirable. Experience has proved it advisable, 
where necessary, to remove almost any portion of this member, patients 
who have suffered its entire; loss being able to swallow, with the exercise 
of a little care, without difficulty. In certain conditions of disease—as, 
for instance, where the epiglottis has been so deformed by contraction as 
to obstruct the larynx, or where it is the seat of severe tubercular dis- 
ease—the removal of the offending portion may be undertaken. This 
is sufficiently easy, and may be effected by the use of the galvanic cau- 
tery, snare, or by properly-curved cutting forceps. New growths of the 
epiglottis, when situated upon its anterior face, are often easy of removal,, 
especially where the growth is not of a malignant character. 
The Uvula and Soft Palate. 
Malformations of the uvula include asymmetry, absence, congen- 
ital elongation, and the condition known as bifid or double uvula. 
Congenital elongation of the uvula has been observed as hereditary. 
This condition, as well as elongation from simple relaxation, is easily 
remedied by the amputation of the redundant part. 
Bifurcation, a result of arrested development, is quite common. To 
relieve the more pronounced cases the tips may be removed, and the* 
inner aspect of each denuded well up to the base, and then brought 
together. 
Amputation of the uvula is now practised with more discretion than 
formerly. The simplest and best instrument for its performance is a 
pair of long-handled scissors, one blade slightly hooked at its tip so that 
the uvula may not slip from its grasp. A holder, made on the principle 
of the thumb-forceps and about eight inches in length, possesses the 
advantages over other forceps that it has not the inconvenient scissors- 
handle, that it may be held firmly and with great steadiness by allowing 
its proximate end to rest in the hollow between the thumb and fore- 
finger, the whole hand meanwhile being steadied bv resting the fourth 
and fifth fingers against the patient’s chin, and, finally, that in applying 
the scissors the forceps may be used as a guide. THE UVULA AND SOFT PALATE. 
181 
In operating, the patient’s tongue should be held down by himself or by an 
assistant with a tongue-depressor, and he should be instructed to breathe quietly, 
so that the throat may be relaxed and the pharyngeal region kept in a quiescent 
state. The amount necessary to be removed having been carefully estimated, the 
uvula, under cocaine anaesthesia, is grasped by the forceps at a point below the 
proposed line of incision and held carefully in position, care being taken to avoid 
stretching it, the result of which is to drag the mucous membrane so far downward 
that in removing it the parts beneath are denuded and the healing process thereby 
greatly retarded. The scissors, carefully guided by the hand and eye of the ope- 
rator, are then applied and the separation of the redundant tissue is completed. 
The same result maybe obtained by means of the Jarvis snare, in the use of which 
it is only necessary to seize the part to be removed in the loop of the £craseur 
without the aid of the forceps. This latter method is not painful if cocaine anaes- 
thesia be employed, and it is sometimes convenient and effective. The amount of 
relief possible from this simple procedure is sometimes remarkable, the symptoms, 
local and reflex, vanishing quickly, the general health returning to a normal basis, 
and the voice gaining markedly in quality and power. In very rare instances 
hemorrhage, troublesome in its character, has resulted from this operation. 
New Growths.—Papillomatous growths, generally of small size, but 
sometimes of sufficient dimensions to cause irritation, are occasionally 
seen upon the uvula near its free extremity, and may be either peduncu- 
lated or sessile. Myxomata and angeiomata may also occur. 
Malignant growths of the uvula and soft palate are occasionally 
encountered, usually, however, as an extension of the disease from adja- 
cent parts. 
Syphilis, tuberculosis, lupus, and lepra of the velum and uvula are 
met with—the first often, the last three rarely. 
Syphilis of the Velum Palati.—The occurrence of the primary 
lesion of syphilis, although now and then observed upon the tonsil, is, 
upon the velum, almost unknown. 
The tertiary form of syphilis may occur in the soft palate at any 
period of time beyond two years after the primary infection. It is 
characterized by true ulceration or loss of tissue, and is the result of the 
degeneration of gummatous deposit. 
The effects upon the velum palati of tertiary syphilis are often most disastrous. 
Two varieties of cases may be described: 1. Those in which simple ulceration has 
taken place at or near the margins of the velum, without material loss of substance, 
so that the adhesions are limited and the greater part of the velum itself is intact. 
In these the progress is good. 2. When the loss of substance has been consider- 
able, and when the soft palate has become extensively adherent to the pharynx, 
relief becomes a matter of extreme difficulty, and in many cases is next to impos- 
sible by any known plan of treatment. Complete adhesion, although rare, is some- 
times seen. 
The results of extensive adhesion of the velum to the pharynx are most dis- 
tressing, and may be summed up as follows : Mouth-breathing; impairment of the 
quality and tone of the voice; interference with drainage from the nasal cavities 
and naso-pharynx; consequent upon this, loss of hearing from irritation of the 
Eustachian tube and the almost inevitable occurrence of serious middle-ear dis- 
ease ; loss of the sense of olfaction. When the passage to the lower part of the 
pharynx is contracted there are sometimes dysphagia and dyspnoea. 
The treatment of this condition consists in the attempt to separate 
the adherent tissues, and to establish, more or less perfectly, commu- 
nication between the upper and lower pharynx. In operating, by 
cutting against the point of a sound passed through the nose into 
the upper pharynx and used as a guide, an entrance may generally be 
effected. 182 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
By skill, ingenuity, and unremitting patience much may be done to 
help the sufferer. 
In general, however, the prognosis is very unsatisfactory. Operations 
must sometimes be done under anaesthesia, and the hemorrhage which 
not infrequently attends such attempts is sufficient to call for the use of 
a tampon-cannula. Secondary hemorrhage is also not uncommon. 
Congenital malformations of the pharynx are of rare occurrence. 
Of congenital malformations of the neck, the pharyngeal fistula is by far the 
most common. This is divided into two varieties, the complete and the incom- 
plete. They are, as a rule, unilateral, and occur more commonly on the right side. 
They are usually incomplete. Their external opening is usually found upon the 
side of the neck, anywhere in the course of a line from the sterno-clavicular 
articulation to the angle of the jaw. Rarely they may open in the median line 
over the larynx or trachea. The internal opening is generally found in the lateral 
wall of the pharynx, behind the cornu of the hyoid bone and near the tonsil, or 
in the pharyngo-palatine arch. The canal varies in length and in diameter, is 
usually somewhat tortuous, and sometimes so much so as to be almost impassable 
to a probe. Its diameter is always greater than that of the external opening, and 
it can be much increased by retained secretions. 
The diagnosis is from the history of the case, the position of the opening, 
and course of the canal as demonstrated by the probe. The existence of an inter- 
nal opening may sometimes be found by probing or by injection through the canal 
of a colored liquid. 
The treatment is sometimes very difficult. It depends upon the destruction 
of the epithelium lining the canal by caustic injections, notably those of iodine; 
by direct cauterization with the galvano-cautery; or by the radical extirpation of 
the fistula throughout its entire extent. Operation is often difficult and dangerous. 
Congenital Malformations of the Pharynx. 
Retropharyngeal Abscess. 
Circumscribed abscesses of the pharynx are generally due to the 
breaking down of lymph-nodes. Their situation in the neighborhood 
of the pharynx causes them to manifest peculiar symptoms and to be 
attended with special dangers. Three varieties may be recognized— 
the retro-, the lateral, and the anterior pharyngeal. 
Chronic abscess of the retropharynx is a common disease in the 
young. It is a serious condition, threatening as it does the life of the 
patient, but one which is, as a rule, entirely remediable by the prompt 
application of proper treatment. 
Although almost invariably found in infants, it has occasionally been 
observed in adult life. A debilitated condition in general, chronic 
cachexia, and the influence of certain infectious diseases may all pre- 
dispose to it. 
A serious form of retropharyngeal abscess is sometimes found in per- 
sons suffering from caries of the cervical vertebrae. 
The early symptoms are like those of ordinary pharyngitis. The 
pharyngeal inflammation, however, continues, and, instead of subsiding, 
the swelling continues to increase. The neighboring cervical lymph- 
nodes may be enlarged. The attack is sometimes sharp and well pro- 
nounced, and in other cases it is slower in its course • the symptoms are 
less conspicuous and the development of the condition is insidious, the 
progress of suppuration being very slow. The first variety is more 
common. Its onset is characterized by high fever, headache, and FOREIGN BODIES IN THE PHARYNX. 
183 
vomiting, sometimes by chills and convulsions. The symptoms of the 
acute sore throat are more or less severe, with considerable pain in 
swallowing. Another prominent symptom is dysphonia. Pain is 
especially marked in the back of the throat and is increased by move- 
ments of the head. 
The treatment of retropharyngeal abscess in its early stages is 
similar to that of acute inflammatory conditions of the pharynx. Upon 
the earliest detection of pus, free incision should be made through the 
posterior wall of the pharynx into the abscess, the most prominent part 
of the swelling or that at which the fluctuation is most distinct of course 
being selected. In doing this the pharynx should be clearly demon- 
strated, full preparation made for the operation, and the instant the 
knife is withdrawn the patient, if an infant, should be inverted to pre- 
vent the escaping pus from entering the larynx. In the adult the 
patient’s head may be caused to hang over the edge of a table. Anaes- 
thesia is contraindicated. 
Lateral abscess of the pharynx may closely resemble phlegmonous tonsillitis. 
It differs, however, from the latter disease in being caused by the suppuration of 
a lymph node. The symptoms are analogous to those of retropharyngeal abscess, 
excepting that dysphonia is less severe. Symptoms caused by irritation of the 
accessory or pneumogastric nerves may sometimes arise. 
External inspection and palpation of the neck may demonstrate the presence 
of a localized swelling in the neighborhood of the angle of the jaw, while an 
inspection of the pharynx will show a condition hard to differentiate from acute 
tonsillitis. 
This form of abscess is commonly acute, and is generally recovered from. Its 
proximity to the great vessels of the neck, and particularly the carotid, renders 
it a source of some danger to these organs. 
Treatment.—Incision is not always possible through the wall of the pharynx, 
and in many cases it will prove easier to reach it from the outside. External 
incision has been highly recommended, because it is the best means of thorough 
evacuation and treatment of the cavity. Where pus has migrated into the mus- 
cular planes of the neck this treatment will of course be required. Hemorrhage 
from one of the great blood-vessels from erosion of its walls is almost necessarily 
fatal. Nevertheless, in such a case the common carotid has been successfully tied. 
Foreign Bodies in the Pharynx. 
Small objects are apt to be lodged in the tonsil or entangled in the 
adenoid tissue at the base of the tongue. Larger substances will be 
more commonly found either in the glosso-epiglottic or the pyriform 
sinuses. The sensations and opinions of the patient as to the existence 
of a foreign body in the pharynx are unreliable, hypersesthesia of the 
pharynx often simulating the latter condition. 
Examination should be conducted by the aid of a strong light and cocaine 
anaesthesia. Irritability may be relieved by the swallowing of ice or very cold 
water. For direct inspection of the throat it is sometimes useful to assist the 
action of the tongue-depressor by pressing upward the thyroid cartilage, thus 
bringing the different parts into view. Failing to discover the object in this way, 
the laryngeal mirror should be used. The practice of digital examination of the 
throat, although valuable, should be made a last resort, on account of the reflex 
irritation which it excites. 
A small object in the tonsil may easily escape detection. It is always well to 
sweep a probe gently over the surface of the gland, and to examine with a rhino- 
scopic mirror behind the palatal folds. The extraction of one object does not 
preclude the possibility of others remaining. 184 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
The treatment depends upon the immediate extraction of the 
offending subject, with means at hand for the proper demonstration of 
the throat and suitable curved forceps to accomplish removal. Where 
the body is lodged very low in the pharynx and is of a shape which 
renders its extraction through the natural passages impossible, entrance 
to the pharynx from the outside may be demanded. The continued 
presence of an irritating body in the throat may give rise not only to 
dangerous local symptoms, but to cough and local irritation of a dis- 
tressing character, causing the general condition of the patient to rap- 
idly deteriorate. 
Lymphoid Hypertrophy at the Vault of the Pharynx. 
Lymphoid hypertrophy at the vault of the pharynx is a condition 
of chronic enlargement of the tissue at the vault of the retronasal space, 
otherwise known as Luschka’s tonsil, the pharyngeal, or the third ton- 
sil. As commonly met with, it is of two varieties. In the first the 
lymphoid element may be associated with more or less fibrous tissue; 
in the second the latter is but feebly represented. The size of the 
growth may be so great as to practically fill the retronasal space, or, on 
the other hand, it may be so small 
as to make it difficult to determine 
whether or not its condition is path- 
ological. It may be confined strictly 
to the vault, or be diffused over the 
posterior and lateral walls of the 
pharynx, or it may exist upon the 
posterior wall of the pharynx alone, 
either in a large well-aggregated, 
tumor-like mass or in more or less 
thickly scattered elevations. 
Its symptoms are, first, those 
due to mouth-breathing—namely, a 
dull, stupid expression of the face, 
anaemia, drooping of the eyelids, 
open mouth, projecting teeth, arched 
palate, pinched nostrils, and the 
deformity of the chest known as 
“pigeon breast.” Again, there is 
mental dulness, loss of hearing, 
nasal obstruction with all the dis- 
tressing symptoms of which it is 
the cause, defective speech, and, 
generally, almost constant catarrh, 
the secretions from which are swal- 
lowed, with the result of producing indigestion. The occurrence of 
reflex effects is shown in frequent headache, irritative cough, laryngeal 
spasm, and other neurotic symptoms, including in some exceptional 
cases such extreme results as chorea and, it is said, epilepsy. Even in 
the infant it may be suspected through the presence of mouth-breath- 
ing, snoring, and a marked inability to perform the act of nursing. 
Fig. 80. 
Position of adenoid enlargement as commonly 
located in the upper pharynx. LYMPHOID HYPERTROPHY AT THE VA ULT OF THE PHARYNX. 
185 
One effect of the obstruction to nasal respiration is the permanent 
deformity of the bony framework of the nose and hard palate which 
generally accompanies it. 
Considering these things, it becomes important to secure the early 
recognition of the necessity for treatment in such cases, and to see 
that it is promptly and efficiently carried out. This must depend in 
some degree upon the nature of the growth, the size to which it has 
attained, and upon the age of the patient. 
In a few instances, where the disease is acute or subacute, where the 
tissue is soft, and the amount of growth small, the application of 
resorptives and the administration of alterative and tonic medicines, 
together with careful attention to hygiene, may possibly accomplish a 
cure. Almost invariably however, these means will be found unsatis- 
factory. In the surgical treatment of this condition by far the most 
effective method is its forcible removal by means of some surgical 
operation. 
For removal by operation many instruments have been devised. These may 
be divided into four classes: a, those made upon the principle of the curette; b, 
the double curette or forceps; c, the wire loop; and, finally, d, the adenomatome. 
The first class includes the ring-knife of Dr. Meyer and its modifications and the 
sharpened finger-nail of the operator, a useful adjunct to the more complicated 
instruments; the second, the forceps of Loewenberg and its varieties; the third, 
a modification of the Jarvis snare; and, finally, the fourth, a double cutting 
instrument, furnished with scissor blades, called the adenomatome. Of these 
instruments, the most generally useful are a modified Loewenberg forceps and the 
sharp curette. 
The other instruments necessary for operating under anaesthesia are a good 
mouth-gag and a soft-palate retractor. The latter should be made with a shank 
broad enough to protect the uvula from injury during the process of operation. 
The position of the patient during operation is of considerable im- 
portance. Two methods, performed under complete ether or chloroform 
anaesthesia, are in common practice: In the first, applicable mainly to 
infants, the child is held upon the lap of an assistant in the sitting pos- 
ture, with the head upright and turned toward a good light. The head 
is steadied by a second assistant, who also manages the mouth-gag and 
administers the anaesthetic. The soft palate may be drawn upward and 
forward by means of the palate-retractor or White’s palate-hook, or it 
may be secured by tapes passed inward through the nose and outward 
through the mouth, the ends being tied outside after Wales’ method. 
With the head inclined forward in this position the blood caused by the 
operation will tend to escape from the mouth, instead of being swallowed. 
Moreover, the pharynx can be well illuminated and the steps of the ope- 
ration better directed by the aid of vision. The position upon the back 
is preferred by many good operators, requiring as it does the services of 
but one assistant, and being the one to which a large majority of sur- 
geons are better accustomed. It is not so favorable as regards the 
admission of light to the pharynx, and therefore it requires a greater 
degree of skill on the part of the operator, whose tactile sense must be 
highly educated by way of substitute. The blood, instead of flowing 
from the mouth, is swallowed into the stomach. This is not a disad- 
vantage, for it trickles down from the posterior wall of the pharynx and 
escapes into the oesophagus almost without making its presence felt, 
unless the flow excited has been considerable. 186 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
A possible objection to the upright position is the additional risk of 
fragments of detached tissue falling into the larynx and thus causing 
asphyxia. Such accidents have been reported, having occurred in the 
Fig. 81. 
Gottstein’s curette. 
course of the use of the Gottstein curette. This would not be possible 
under the use of the forceps. 
The management of the palate-retractor should be entrusted to a 
skilled assistant, as upon this the convenience, and to some extent the 
success, of the operation will depend. 
Removal by curette or forceps is sometimes practised without anaesthesia. 
While it may be called for in some cases, it is apt to be exceedingly painful, and 
far less thorough than by the method just described. 
The operation is attended with more or less bleeding, generally of no import- 
ance, but sometimes considerable. It is best, therefore, that the tissue be torn 
away rather than cut. This method has the additional advantage of greater 
thoroughness, as masses of adenoid much larger than the fragment grasped by the 
instrument are frequently separated, and by this method it is not likely that the 
healthy and more resisting parts will be injured. Remnants left by the forceps 
may be removed by the finger-nail, by Hooper’s forceps, or by means of a small 
carefully-guided curette. Should the removal of a mass of adenoid be followed 
by undue bleeding, it is well to defer further attempts at operation for a few 
moments until the hemorrhage shall have ceased, or, at least, until it shall have 
sufficiently diminished. Too great force in the separation of a fragment of tissue 
must be avoided. It is better to release the mass included in the grasp of the for- 
ceps and seize a smaller portion, or else, by applying them in a somewhat different 
position to separate adherent fragments, than it is to attempt to accomplish too 
much at once. As large masses of hypertrophied tissue often exist upon the pos- 
terior wall of the pharynx as well as upon the vault, it is necessary to secure the 
removal of these with the rest. The corners of the upper pharynx also, immedi- 
ately above the Eustachian prominences, must be carefully cleared. 
In operating upon the upper pharynx general anaesthesia is of the greatest 
possible value both to the physician and to the patient. With it ample time is 
afforded for careful examination and for the checking of undue bleeding should 
any occur; perfect control of the operation, as well as of the patient, can be main- 
tained; absolute relaxation of the throat can be secured; the inducement of 
retching from pharyngeal irritation, that most active and persistent of reflexes, 
can be avoided ; troublesome remnants of the growth can be recognized and 
removed; undue excitement can be prevented ; and finally, the whole work can 
be accomplished without the knowledge on the part of the patient of what has 
been done. 
Following operation, the general condition should be made as perfect as possi- 
ble, change of air often being beneficial, and the patient should be carefully 
examined in order to determine whether or not the operation has resulted in a 
thorough and complete success. Should the contrary prove to be the case, further 
treatment may be called for, and although, when properly performed at first, it 
Avill seldom be necessary to repeat the operation, there is no reason why this 
should not be done when required. Indeed, it is well in difficult cases to mention 
to the parents beforehand the existence of such a possibility, especially in dealing 
with very young patients. 
Nasopharyngeal. Tumors. 
This variety of growth, fortunately, is of rare occurrence. It origi- 187 
NASOPHARYNGEAL TUMORS. 
nates usually about the time of puberty, tending to subside after the 
patient is of age, and is most common in males. 
The etiology is unknown. The tumors generally arise from the 
basilar process of the occipital bone and the base of the body of the 
sphenoid, whence they may extend to almost any part of the pharynx, 
the nose, or its adjacent sinuses. The development of the growth is 
active up to the twentieth year. After this, however, it ceases to grow, 
and by degrees will atrophy and practically disappear. While not highly 
malignant in itself, it is exceedingly dangerous from the destruction to 
surrounding parts which attends its progress. Inspection shows that 
the surface of the tumor is smooth, even, and rounded, and numerous 
large vessels may appear upon it; its color varies from a pale pink to a 
deep, congested reddish color. In the nasal fossa the growth appears 
dark red in color, dense in structure, firmly attached, and easily made 
to bleed. The membrana tympani are of course depressed, owing to the 
interference with nasal respiration. 
Treatment.—While its base is still absolutely limited to the 
pharynx, operation through the natural passages is clearly and unmis- 
takably indicated. For this purpose the Scraseur, either in the form 
of the galvano-caustic loop or the cold snare, has been found decidedly 
the most practical. In the employment of the electric loop the best 
method is, if possible, to surround the base of the growth with the 
galvanic ecraseur, passed either through the nose or through the mouth. 
The inclusion of the growth within the loop is often difficult. Much 
easier manipulation is made possible by the use of a separable double 
cannula, through which the wire may be passed. The curved cannula, 
carried behind the palate, is inferior to that used through the nose. 
The loop, aided by the finger in the pharynx, should be fixed to the 
highest possible point. 
The above directions relating to the cold snare will apply as well to 
the incandescent loop, which is in some respects superior. With the 
latter the density of the growth may be more readily overcome, result- 
ing in the destruction of some of the remaining tissues, and the danger 
of hemorrhage almost entirely done away with. Only a moderate 
degree of heat should be applied. Attempts to tear the growths away 
piecemeal will be likely to cause serious hemorrhage, and are absolutely 
contraindicated. 
Excision without preliminary operation is, from the danger of hemor- 
rhage, unjustifiable. 
Ligation is sometimes useful. The use of the galvano-cautery, both 
in the form of the loop and for the destruction of remnants or of points 
of recurrence, makes it possible to thoroughly eradicate fibromatous 
growths. The electrolytic method is sometimes of great value. 
Great aid is afforded the surgeon in these manipulations by the inva- 
riable enlargement of the pharyngeal space which is present. 
When the growth has advanced beyond the vault of the pharynx 
and removal by the natural passages is impossible, the old method of 
removal after a preliminary operation must be discussed. While such 
radical procedures have now and then succeeded, the general statement 
may be made that they are far inferior in safety and success to early 
operation with the loop. Three varieties of procedure have been 188 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
employed—namely, operation carried on through the nose, through the 
mouth, or through an entrance effected by operations more or less for- 
midable upon the superior maxillary bone. 
Fibro-mucous Polypi.—These are composed of a mixture of the 
structural elements of the tissue from which they originate. They vary 
from a tumor of small size to one sufficient to fill the upper pharynx, and 
are generally smooth, dark red, and ovoid in form. They are probably 
more common than true fibromata. 
The symptoms to which they give rise are principally those of nasal 
obstruction. They are otherwise harmless to the surrounding structures, 
and are not prone to bleed. They show little tendency to recur when 
removed, and may be extirpated by evulsion, or, better still, bv the cold- 
or the hot-wire loop. 
Enchondroma.—Enchondroma of the nasopharynx is extremely rare. 
Malignant Tumors.—Malignant tumors of the nasopharynx, al- 
though rare, are really less uncommon than has been supposed. 
The symptoms are similar to those of fibromata, but to these are 
added in certain cases severe pain of a lancinating character, which is 
apt to be referred to the ear and to be worse at night, severe dysphagia, 
and general cachexia. Sarcomatous tumors may be pedunculated, while 
sometimes they are more or less distinctly lobulated. They present no 
special features to the eye or to the touch by which their true nature can 
be detected. 
The latter can be established by the aid of the microscope. 
The prognosis is absolutely bad. The progress of development is 
rapid, and recurrence after removal is almost certain. 
The best plan of treatment consists in early recognition of the 
growth and its removal by the galvano-cautery or by electrolysis, any 
sign of recurrence being attacked at once. 
Epithelioma.—Carcinoma of the pharynx is rare. In such cases 
the comfort of the patient may be enhanced and the progress of the dis- 
ease retarded by the repeated thorough removal of the soft, fungating 
masses which fill the upper pharynx. 
Dermoid Tumors.—These rare abnormalities are undoubtedly con- 
genital. 
Chronic Hypertrophy of the Tonsils. 
Chronic enlargement of the tonsils consists in an abnormal increase 
of the lymphoid tissue of the organ, sometimes accompanied with a pro- 
liferation of its fibrous stroma. The latter is apt to occur where the 
disease is of long standing, although not uncommon in the young. The 
hypertrophic process is most active at the age of puberty, after which 
time it tends to decline until beyond thirty the disease is more uncom- 
mon. It may originate, however, at almost any time before adult life. 
It has been present in old age. 
The symptoms are usually plain and easily recognized, and are in 
many particulars similar to those which accompany the local obstruction 
and irritation found with lymphoid hypertrophy at the vault of the 
pharynx. In some cases the tonsils are chronically inflamed, without 
being materially enlarged, the condition giving rise to annoying symp- CHRONIC HYPERTROPHY OF THE TONSILS. 
189 
toms. These cases may be much relieved by the application of astrin- 
gents to the crvpts, or, still better, by the opening up or cauterization 
of such of the latter as are either dilated or inflamed. 
Tonsillotomy.—Of the methods for removing the tonsil most com- 
monly used, may be mentioned cauterization by chemical or electrical 
escharotics; ecrasement, by means of the galvano-caustic loop or of the 
cold wire; abscission, by means of some modification of the knife or 
scissors. Both ligation and the injection into its substance of various 
supposed absorbents only need be mentioned to be condemned. The 
practice of enucleating the tonsil with the finger has lately been revived 
in some quarters. Excepting in young children it is of questionable 
value. 
During the operation the patient should sit facing a good light, the 
operator with his back to it. By those familiar with the use of the 
head-mirror the latter, however, will generally be preferred. The 
patient, if an adult, should sit upright and well back in the chair, the 
head fixed against a properly-adjusted head-rest or supported by an 
assistant. The latter should stand directly behind the chair, and, while 
holding the head with both hands, should place the fingers of each hand 
over the tonsillar region of the corresponding side—that is, immediately 
below the angle of the jaw. Thus the tonsils may be prevented from 
receding before the pressure of the tonsillotome when it is introduced, 
and the operation may be performed with greater accuracy and thor- 
oughness. 
Having engaged the tonsil in the ring of the instrument, push the 
blade firmly and steadily through the included tissue, separate the frag- 
ment of tonsil, and, withdrawing the instrument quickly, remove the 
excised gland adhering to it, and at once, and before the patient realizes 
that there is to be a second operation, before bleeding sets in, and with- 
out giving opportunity to cough or clear the throat, excise the remaining 
gland. Thus both may be removed at one sitting, so that but one con- 
valescence is to be endured : few young patients will submit to a repe- 
tition of the operation. The Physick tonsillotome has been modified, so 
that the handle may be reversed, enabling it to be used first in one hand 
and then in the other. Ambidexterity in the use of the one instrument 
is far better. The operation may generally be done very quickly. 
As a rule, anaesthetics are not indicated in tonsillotomy. Cocaine anaesthesia is 
often effective, although, if the child is highly sensitive, irritable, or feeble, chloro- 
form or nitrous oxide may be desirable. The introduction of the instrument into 
the pharynx is often more complained of than the actual separation of the tonsil. 
Bleeding after operation is usually slight, and soon ceases spontaneously; if 
not, it may generally be checked by simple means, such as direct application to 
the cut surfaces of a mixture of one part gallic and three parts tannic acid, slightly 
reduced with water and applied upon a pledget of cotton. The sucking of cracked 
ice is also effective. Sometimes, however, hemorrhage may be severe, and, while 
fatal results have very rarely occurred, there are several cases on record in which 
this accident has taken place. With regard to this question, it may be said that 
moderate hemorrhage requiring direct pressure or astringents to check it is not 
very unusual: a severe hemorrhage occasionally occurs, and in view of the enor- 
mous number of tonsillotomies done the proportion of serious results has been 
exceedingly small. The source of the bleeding may be either arterial, from the 
division of one or two comparatively large arterial branches, or from the division 
of a large number of small arterial twigs; venous, from the division of the small 
plexus of veins which lie outside and below the tonsil; and capillary or general, 190 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
from the presence of the hemorrhagic diathesis. The records show that hemor- 
rhage has very rarely occurred before the eighteenth year. This may be explained 
by the presence of the larger amounts of fibrous tissue in the adult tonsil. Park 
has discovered a new styptic of extraordinary efficiency, easily made by mixing 
fairly strong (25 per cent.) watery solution of antipyrine and alcoholic solution of 
tannin. A most tenacious, gummy mass is thrown down, which when applied on 
cotton or sponge with a little pressure will check all oozing. 
Foreign Bodies in the Tonsil. 
Foreign bodies may develop spontaneously in the tonsillar crypts 
through retention of the secretions of the latter. The presence of such 
a cheesy mass may give rise to much irritation. The condition should 
be relieved by removal of the deposit and free opening of the crypt. In 
rare instances a true calculus of the tonsil has been found. The presence 
of a tonsillar calculus may be determined by the discharge of fragments 
of the calculus, by inspection, a part of the mass being visible, or by 
examination with the finger or probe. Their removal may be accom- 
plished either by enlarging the mouth of the crypt and extracting them 
or by excision of the tonsil. Their presence may pass unnoticed, not 
only by the patient, but by the physician, the symptoms often being 
obscure. 
Tumors of the Tonsils. 
Tumors of the tonsils requiring radical operation are usually malig- 
nant, and are either epitheliomatous or sarcomatous. The latter are 
generally of the round-celled variety. The rapidity of their growth, 
their tendency to recur, the readiness with which the neighboring lym- 
phatic nodes become infiltrated, and, finally, the important anatomical 
position of the tonsil, all militate against the success of efforts made to 
remove them. Operation may prolong life and give a certain measure 
of relief, however, and in some cases at least it has effected a cure. It 
should never be attempted without the clearest possible understanding, 
not only of the normal regional anatomy of the vicinity, but, in partic- 
ular, of the important arterial trunks near by and their possible anoma- 
lies. Tumors of the tonsils may be removed through the mouth or 
through incision in the neck and into the pharynx. The latter method 
is called pharyngotomy. 
Operation through the Mouth.—In cases where the tumor is well 
defined and projecting, as in the case of some sarcomata, and, now and 
then, of epitheliomata which have developed in an already enlarged 
tonsil, removal may be successfully accomplished by means of the gal- 
vano-caustic loop or even with the cold-wire ecraseur, and such diseased 
tissue as remains subsequently taken away by any suitable method which 
may recommend itself. Even in this operation a preliminary trache- 
otomy is sometimes necessary. This method is less dangerous, and its 
results are as good as those of the more severe operations. 
From the depth and obscurity of the parts a good light is indispen- 
sable. The writer has employed with great satisfaction a small incan- 
descent electric lamp, which, introduced into the deepest recesses of the 
pharynx, demonstrates clearly the various parts under observation, thus 
enabling the surgeon to distinguish between affected and healthy tissues 
and to locate accurately any bleeding point. Such a lamp, of from one- TUMORS AND POLYPS OF THE NASAL CAVITIES. 
191 
to three-candle-power, should, if possible, be provided in case its use be 
required. 
The three principal operations known as pharyngotomy for the 
removal, from without, of malignant tonsillar disease are Cheever’s, 
Czerny’s, and Mikulicz’s. 
Tumors and Polyps op the Nasal Cavities. 
The form of tumor known as simple mucous polyp, naso-fibroma, or, 
incorrectly perhaps, nasal myxoma, is by far the most common form of 
neoplasm found in this region. 
The etiology of these growths is obscure. Their duration is often 
difficult to determine. 
The symptoms are, in general, those of obstruction to breathing, loss 
of the olfactory sense, local irritation, and persistent catarrh. They 
are usually referred to a time at which the patient became especially 
susceptible to acute coryza: the symptoms have grown progressively 
more annoying, and they finally reach a state where they are incessant. 
When located comparatively high or confined to one side, the patient 
may be unaware of their presence. On the other hand, the growths 
may actually protrude from the vestibule of the nose. As nasal obstruc- 
tion becomes more pronounced the symptoms and the general discomfort 
become more severe. Mouth-breathing, snoring, and fatigue upon com- 
paratively slight exertion are usually present. Ileflex symptoms are 
not uncommon, such as headache, oftentimes severe, neuralgia in 
different localities and especially through the distribution of the facial 
nerve, reflex cough, and, finally, marked asthmatic attacks and neuras- 
thenia. The eye may suffer from irritation of the conjunctiva and 
lachrymation and from various more or less obscure disturbances of 
vision. The auditory apparatus may also be seriously affected, owing 
to the obstructed nasal respiration, the catarrhal inflammation, and the 
possible reflex irritations which the polyps may excite. Vertigo, impair- 
ment of memory, mental hebetude, and insomnia are more or less com- 
monly observed. The symptoms of coryza may vary from a tendency 
to sneezing and to the appearance of a watery discharge, apparently 
from slight exposure to cold, to catarrhal symptoms of the most pro- 
nounced and inveterate character and with excessive secretion. Pro- 
nunciation is affected, and the tone-quality and carrying power of the 
voice greatly impaired. The peculiar inability to fix the attention in 
these cases is called aprosexia. 
The treatment of nasal polyps should be first, thorough removal, 
and, second, prevention of recurrence. For the former various means 
have been employed from an early period, some of which are still in 
use. External applications to the growth are generally ineffective. 
Rarely, astringents may retard development and add to the comfort of 
the patient. The means most commonly employed, however, are those 
by which the growth is removed with forceps, separated by means of a 
wire snare, or destroyed by the galvanic cautery or ring knife. In 
order to operate intelligently and successfully the nasal cavity, under 
cocaine anaesthesia, should first be demonstrated by anterior rhinoscopy, 
the removal of as many polyps as possible effected, and, when sufficient 192 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
hemorrhage has occurred to obscure the parts, further operation deferred 
until another sitting. Variously constructed forceps are used for this 
operation, and for the removal of certain varieties there is no better 
method. In general, alligator forceps, the jaws of which should be 
serrated and not too large, will be found the most convenient. The 
most generally useful and least painful instrument for the removal of 
polyps is the Jarvis snare. For the removal of small growths situated 
Fig. 82. 
Jarvis snare. 
high in the nasal cavity a finer quality of piano wire than that com- 
monly employed is desirable. 
The removal of cystic growths is often difficult from their great size. 
Incision into the wall of the tumor will, if it be a cyst, cause it to col- 
lapse, when it can be removed with ease. The galvano-caustic loop for 
the removal of simple nasal polyp is seldom necessary. A fine ring 
knife is sometimes useful for the removal of growths which are hard to 
reach by other means. 
Little immediate treatment is needed after operation beyond pro- 
tecting the sensitive membrane from the too free access of the air, 
especially in bad weather, and the keeping of the parts properly cleansed 
and disinfected. The necessity for aseptic instruments is emphasized 
by the fact that dangerous pysemic symptoms have followed the care- 
less removal of a simple mucous polyp. 
For the prevention of recurrence the growths must not only be 
removed, but the localities from which they have originated must be 
absolutely freed from all trace of their presence. Either at the time of 
removal or subsequently applications of the galvano-cautery or other 
caustic should be made for this purpose. The nasal cavities should be 
treated locally meanwhile with alkaline and antiseptic sprays and, if 
necessary, with astringent solutions. Removal of the anterior extremity 
of the middle turbinated for access to the region which it covers may 
sometimes be required for the extirpation of polyps, but should be 
practised with great caution. 
In the rare event of polyp appearing in the course of an atrophic 
rhinitis, its presence may act as a stimulus to secretion, and thus prove 
helpful. 
Insects and Foreign Bodies in the Nose. 
The impaction of a foreign body in the nose is a common accident. 
The entrance of living organisms, on the other hand, is somewhat rare 
in temperate latitudes, but sufficiently common in tropical and subtropi- 
cal countries. While the former seldom gives rise to severe symptoms, 
the latter may readily prove fatal. 
Foreign bodies are most apt to lodge in the widest part of the canal. 
Any object sufficiently small and capable of locomotion, such as an in- 
sect, may find its way into one of the adjacent sinuses. A foreign body INSECTS AND FOREIGN BODIES IN THE NOSE. 
193 
may give rise to great irritation, as may also attempts made to ex- 
tract it. 
The variety of foreign bodies which have been found in the nose is 
very great. The list comprises extraneous substances introduced either 
by accident or design by infants or insane adults; sequestra of diseased 
bone; and parasites. 
The history is usually as follows: A child of about two years of 
age unobserved thrusts some small rounded object into its nostril. Soon 
symptoms of unilateral chronic inflammation are established, the irrita- 
tion often being severe and the discharge extremely fetid. The body, if 
too firmly impacted to be dislodged by simply blowing the nose, remains 
fixed until removed by the surgeon. Not infrequently the presence of 
a foreign body passes unsuspected for many years, and the child is treated 
indefinitely for simple catarrh. 
Treatment.—Preparatory to removing a foreign body first cleanse 
the mucous membrane anterior to it. Then thoroughly anaesthetize the 
membrane with a 6 per cent, solution of cocaine. The passage thus hav- 
ing been widened, the body may often be extruded by simply blowing 
the nose. Should it still be so firmly impacted as to require the use of 
an instrument, its removal will be greatly facilitated by the anaesthesia 
of the parts as well as by the additional space provided. A probe or 
small forceps will often answer the purpose of extraction. If necessary, 
the body may be first crushed. The copious hemorrhage which com- 
monly results from the old method of extraction is not likely to follow 
after the use of cocaine, for the reason that less injury is done to the 
parts. 
In all cases of fetid catarrh, particularly when confined to one side 
and dating back to infancy, careful examination with speculum and probe 
should be made, the nostril having first been thoroughly cleansed by 
means of a warm douche and the presence of a foreign body excluded 
before a positive diagnosis is made. 
Diagnosis is generally easy. In some cases, especially of long stand- 
ing, the foreign body may be completely concealed by the secretions of 
the nose or by a mass of granulations. In the latter case the appear- 
ances have often been mistaken for syphilis, malignant disease, or lupus. 
Examination with a probe will at once determine the nature of the 
trouble. 
After removal of the object the nostril should be washed several 
times a day with a weak disinfectant. Cure quickly follows. 
The so-called rhinoliths, or nasal calculi, are concretions formed of 
the earthy salts of the nasal secretions. Sequestra of bone, particularly 
in tertiary syphilis, sometimes remain in the nasal cavity after their 
separation, thus acting as foreign bodies. 
Fungi and Parasites.—Various fungi, as well as ascarides, leeches, centi- 
pedes, and earwigs, have found their way into the nasal cavities. The symptoms 
commonly present after such an accident are epistaxis, sneezing, headache, lacliry- 
mation, nasal discharge, and stenosis. 
In the tropics, seldom elsewhere, various kinds of flies may enter the nasal 
chambers, preferably of a patient suffering from catarrh, and there deposit their 
eggs. These are quickly hatched, causing in succession irritability, tickling, and 
sneezing; later, formication, bloody discharges, and epistaxis, with redness of the 
face, eyelids, and palate; excruciating pain, generally frontal, insomnia, and, if the 194 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
condition continue unrelieved, necrosis of the parts, convulsions, coma, and death. 
Sometimes the larvrn are sneezed out, or they may be seen on examination of the 
nose, which of course will establish the diagnosis. The destruction caused by them 
may extend to the mucous membrane, the cartilages, and even to the bones of the 
head, the ethmoid, sphenoid, and palate bones having been found carious. The 
extension of the destructive process is often very rapid. 
Treatment should be prompt and efficacious, and should be selected some- 
what with reference to the stage of development of the larvaj and the progress 
which the condition has attained. If the case can be seen before the larvae have 
migrated too far or have buried themselves too deeply, it is possible to cause their 
immediate and thorough expulsion by local cleansing, cocaine anaesthesia, and the 
inhalation of chloroform or of ether, the effect of the last-named drugs being to 
cause the insects to voluntarily vacate the nose. Insufflations of calomel and injec- 
tions or infusions of tobacco, of turpentine, and of alcohol have been recommended. 
Of these, the two former seem to have given the best results. As failure to obtain 
relief is fatal, the propriety of surgical operation in extreme cases is worthy of 
consideration. 
Rhinoscleroma. 
This rare condition involves both the integument and the mucous 
membrane of the nose, whence it extends indefinitely. The disease 
appears in the form of well-defined tubercles, rounded prominences, or 
flat structures of considerable density, which begin upon the alae and 
adjacent parts of the lips. The tubercles may be of the color of the skin 
or else of a brownish red, shiny upon the surface, devoid of hair, and 
traversed by dilated blood-vessels. Rigidity of the affected parts becomes 
apparent in consequence of the infiltration. 
Pathologically, the growth seems to resemble round-celled sarcoma, 
although differing from it by the presence of certain small hyaline bodies 
of highly refracting power which seem to form its characteristic element. 
The latest investigations seem to demonstrate that certain microbes are 
an evident factor in its propagation. The fact that it is infectious has 
been proved by successful inoculation of the cultures of these micro- 
organisms. ( Vide p. 217, as well as Vol. I. p. 76.) 
The disease must be differentiated from syphilis by the failure of con- 
stitutional treatment; from epithelioma by the appearance of the ulcer- 
ation ; from keloid in that microscopically the latter is composed entirely 
of fibrous tissue. 
The only known treatment is excision. 
Epistaxis. 
Epistaxis, or hemorrhage from the nasal cavities proper and their 
accessory sinuses, may be either active or passive. It may occur from 
violence, from some remote pathological condition, or as a vicarious phe- 
nomenon. The former is the most common. The bleeding may come 
from one nostril alone or from both. It may originate in the deeper part 
of one nasal cavity, and, owing to some stoppage on that side, be deflected 
into the nasal cavity of the opposite side, and emerge through that nos- 
tril or into the pharynx. Hemorrhage occurring during sleep, and the 
patient in such a position that the blood gravitates into the pharynx, 
might easily escape detection until serious loss of blood had resulted. 
Changing the position of the patient and causing him to clear his throat 
would probably demonstrate the presence of the bleeding. EPISTAXIS. 
195 
Treatment.—Before attempting to treat epistaxis it is necessary to 
determine, as far as possible, its precise origin and cause. Vicarious 
hemorrhages and those occurring at the critical period of certain fevers 
may be allowed to continue unless excessive. With the plethoric also, 
and especially where it appears instead of menstruation, it should not 
be hastily interfered with. To stop the flow simple means will gener- 
ally prove effective, such as absolute rest, the supine position, avoidance 
of allowing the head to hang forward, and standing with the head erect 
and the arms raised above it. The application of cold to the nose and 
the insufflation of cold water are effective, while the injection of water 
as warm as can be borne is an excellent styptic. Whenever possible 
direct applications should be made to the bleeding point, the latter hav- 
ing been carefully dried, with absorbent cotton, of nitrate of silver, of 
chromic acid, or of the galvanic cautery. Various astringents, such as 
alum and tannin, may also be used directly upon the bleeding point. 
The injection of a solution of antipyrine, from ten to twenty grains 
to the ounce, has been found effective. If necessary, control of the 
hemorrhage may be gained by plugging the parts in the neighborhood 
of the bleeding. Anteriorly, this may easily be accomplished by pack- 
ing against the bleeding surface a tampon of absorbent cotton, or, still 
better, one composed of a narrow strip of surgical gauze upon which 
some styptic—as, for instance, tannin—has been sprinkled. Park has 
Fig. 83. 
Plugging the nares with Bellocq’s cannula (Fergusson). 
recommended most highly the combination of solutions of tannin and 
antipyrine (each of 10 per cent.), by whose union a most tenacious and 
powerfully styptic substance is formed. This may be applied directly. 
Occurring posteriorly, the bleeding may be checked by inserting a tam- 
pon in the nasopharynx, and, if necessary, at the same time packing the 
anterior part of the nasal canal. For this a flexible catheter or Belloeq’s 
cannula is used. 
The latter consists of a cannula curved at one end, through which is passed a curved 
steel spring, the end of which is protected by means of a perforated ball. In order to 196 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
use the Bellocq cannula a loop of silk should be threaded through the eye in the end 
of the cannula. The steel should be drawn backward into the cavity of the can- 
nula before the introduction of the latter into the nasal canal. To introduce the 
cannula pass the extremity with the silk loop through the nostril and backward 
along the floor of the nose to the posterior wall of the pharynx. Having reached 
the latter, thrust the steel spring forward, so that it shall emerge from the cannula 
and appear beneath the soft palate. A tampon of cotton, lint, or sponge, saturated 
with vaseline, should have previously been prepared and attached to the middle of 
a stout piece of soft woven silk, the latter about eighteen inches long. One end 
of this silk should now be securely tied to the loop of silk in the eyelet of the 
cannula, and with the aid of the latter, assisted by the finger placed in the phar- 
ynx, the string should be drawn forward through the nasal cavity until the tam- 
pon arrives in the lower pharynx. Here, by means of gentle traction made upon 
the string, combined with careful pressure upward from the finger, the tampon 
should be forced into the upper pharynx as desired. The tampon having been 
duly placed, it is well to make a firm block of absorbent cotton, around which the 
anterior nasal end of the string may be wound and held in the vestibule of the 
nose. The pharyngeal end of the string should be conducted out of the mouth 
and loosely attached to the patient’s ear. In removing the tampon there is con- 
siderable danger that the parts may be irritated and thus the bleeding again pro- 
voked. It should never be drawn forcibly from the pharynx. The best plan, as a 
rule, is to first cleanse the parts as thoroughly as possible, and then apply a weak 
solution of cocaine in order to cause as much contraction of them as possible. 
While it may be considered in some cases necessary to do so, it is not desirable to 
allow the tampon to remain in the pharynx for more than twenty-four hours. 
Severe bleeding may require the use of revulsives intended to cause reflex con- 
traction of the nasal blood-vessels, the administration of remedies intended to 
quiet the action of the heart, the application of pressure internally as well as ex- 
ternally, and, in extreme cases, transfusion or some kindred measure. 
The Accessory Sinuses. 
The sinuses adjacent to the nasal cavities, and communicating with them, 
are four in number—namely, the frontal/ the ethmoidal, the maxillary or antrum of 
Highmore, and the sphenoidal. It may be said of them all that they are located in 
regions of great anatomical importance, that the diseases to which they are sub- 
ject are of an unusually serious character, and that the treatment which the latter 
may require for their relief is such as to demand the highest degree of special 
skill. 
The accessory sinuses may be the seat of hypereemic and of in fective 
processes. The first condition generally complicates an attack of acute 
rhinitis, and may be difficult to distinguish from the latter except for 
the localized pain which it may occasion. Suppurative disease of these 
parts is an affection of much greater importance, the symptoms being 
more severe and the resnlts more serious. The most important of the 
latter is the development of various abnormal conditions of the soft 
tissues lining the cavities, and of caries or necrosis of the bony struc- 
tures underlying them. These diseases may develop from simple acute 
catarrh, from chronic rhinitis, or, in exceptional instances, from trau- 
matic causes. In the maxillary sinus disease is often due to dental 
irritation. Local destructive processes accompanying syphilis or tuber- 
culosis may possibly give rise to them. 
The exciting cause of the trouble is usually a lack of free drainage 
of the sinus through its natural opening. The chief causes may be 
regarded as occlusion, followed by acute, and later bv chronic, suppura- 
tion. The inflammatory processes resulting from this extend to the 
periosteum, and necrosis finally supervenes. The obstruction to the 
canal may be either in its continuity or at its mouth, in the latter case THE ACCESSORY SINUSES. 
197 
caused by thickening of the soft tissues surrounding it or deformity of 
the adjacent bony parts. 
The symptoms of sinus disease are often obscure, and diagnosis 
difficult. When pain is present, it may be of two kinds: the first is 
deep-seated, dull, and throbbing, and located in the neighborhood of the 
affected sinus. In addition to this, neuralgic pains of the most intense 
character may appear, sometimes distinctly radiating from the affected 
centre and sometimes difficult to trace. In the more chronic cases pain 
may be more or less wanting. External swelling over the frontal and 
maxillary sinuses may be present in extreme cases. The location of 
the pus exuded into the nasal cavity, although apt to be misleading, is 
sometimes a guide as to its source, that issuing from the ethmoidal cells 
or the maxillary sinus pouring downward from beneath the middle or 
the anterior border, respectively, of the middle turbinated body. By 
the method of transillumination pus may be demonstrated in unilateral 
disease of the maxillary and frontal sinuses, although this test is not 
always to be relied upon. 
The principles of the treatment of these diseases may be summed 
up under three heads—namely, free drainage, systematic cleansing of 
the cavities, and removal from them of diseased tissues and bone. The 
special application of these principles to the different sinuses requires 
separate consideration. 
In general, however, it may be said that in case of acute inflammation occur- 
ring in any sinus active measures should be taken to subdue it, both by general 
measures and by such local means as shall subdue the swelling and congestion in 
and around the sinus-canal. Dilatation of the parts by sprays of cocaine, fol- 
lowed by the use of cleansing sprays, the use of steaming inhalations, and, finally, 
the absolute avoidance of all irritating applications, will often greatly hasten 
recovery. Cure may sometimes be effected in the less severe chronic conditions 
by removal from the points of exit of the sinus-canals of any hypertrophic tissue, 
polypoid growth, or other obstructive condition which may interfere with the 
drainage of the part. In cases not amenable to the above treatment more severe 
surgical measures involving forcible entrance into the sinus may be required. 
The interior of the frontal sinus may be approached from one of 
three points—namely, through its floor from just above the inner can- 
thus of the eye; from in front, by an incision parallel with the upper 
margin of the eyebrow; and from in front, by a vertical incision a little 
to the median line. The bony wall of the sinus may be so thinned as 
to be penetrated with ease. Should this not be the case, entrance may 
be effected by the use of the chisel or trephine. If necessary the walls 
of the sinus are scraped and diseased tissue, polyps, and diseased bone 
removed. In all cases drainage should be established from the sinus 
through the natural canal into the nasal cavity. To secure this Mayo 
Collier carries a piece of soft rubber tubing from above through the canal 
and out of the nose. The diameter of the tube is sufficient to completely 
fill the calibre of the canal, and thus prevent its walls from becoming 
thickened. To irrigate the wound the tube is put upon the stretch: 
its diameter is thereby lessened, and the antiseptic fluid is injected from 
the wound above downward and into the nose. The rubber tube is 
retained for from six to ten days, when it is removed and the outer 
wound closed. 
Others advise that the cavity be packed with antiseptic gauze and 198 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
allowed to heal from the bottom, the external wound meanwhile being 
kept open. 
Several methods are employed for treatment of suppurative disease of 
the maxillary sinus. These are of two varieties—namely, by entrance 
to it from within the nasal cavity, and from without. Where the ostium 
maxillare is sufficiently large and accessible, a small tube may be passed 
through it, and the interior of the antrum thus irrigated. In case the 
above conditions are not present, an artificial opening can be made 
through the wall of the antrum at the level of the floor of the nose. 
Through this systematic irrigation can be maintained. 
By far the most popular way, however, is to enter the sinus from 
without, either by withdrawing a tooth and breaking into the floor of 
the antrum perpendicularly through its socket, or by drilling an open- 
ing horizontally through the alveolar process in that part known as the 
canine fossa. 
If necessitated by the severity of the condition, a considerable section of the 
outer wall of the antrum may be removed and its cavity thoroughly exposed. 
Various devices in the way of tubes of metal or rubber are used for the purpose 
of keeping the opening patent, and of thus permitting the treatment to be con- 
tinued for an indefinite length of time. Of the various methods mentioned, 
entrance through the canine fossa is, on the whole, the best. 
Where suppurative disease of the ethmoid cells is present ob- 
structive thickenings must be removed, polyps destroyed, malpositions 
of the anterior end of the middle turbinated body relieved, or the walls 
of the cells entered. Preliminary to the latter operation, it may be 
necessary to expose the region by the actual removal of the anterior end 
of the middle turbinated body. This having been done by means of the 
Jarvis snare or a suitable cutting forceps, the anterior wall of the ethmoid 
cells is penetrated, and, if required, the bony septa which divide the 
various compartments are broken up sufficiently to allow of the free 
irrigation of the whole cavity. 
Disease of the sphenoidal sinus, the most difficult of all to reach, 
has sometimes been relieved by puncture of the anterior wall of the 
sinus and subsequent irrigation. 
The treatment of chronic disease of the maxillary sinus is difficult, 
and often exceedingly tedious operations upon the other sinuses are too 
serious to be entrusted to any but the most skilful hands. 
When it is remembered that the cavity of the sinus is separated from 
the orbit by an exceedingly thin plate of bone, and that its proximity 
to the brain is also intimate, it will be unnecessary to urge the import- 
ance of duly appreciating the serious character of such operations, the 
observance of due conservatism in resorting to them, and the employ- 
ment of a high grade of skill in carrying them out. It is safe to say 
that in no part of the body is a thorough knowledge of the anatomy of 
the parts more urgently necessary. 
Treatment of the case after the operation should consist in thorough 
and persistent cleansing of the parts until relief has been gained. 
Congenital deviations from the normal condition of the nose are 
sometimes found, consisting in absence or reduplication of the whole 
Deformities of the Nose. FRACTURE OF THE NASAL SEPTUM. 
199 
organ or of any of its constituent parts, in complete or partial closure 
of its canals, or in abnormalities of size and shape of certain of its parts. 
With the exception of the last-named conditions, which are common, 
these deformities are rare. 
Of the acquired deformities of the nose, deviations of the nasal sep- 
tum are so common as to be the rule. Practically, they are the most 
important abnormalities of the nose with which the surgeon has to deal. 
Undoubtedly the most common cause of septal deflection is trauma- 
tism. Some of the worst cases, however, occur in those who have been 
mouth-breathers from pharyngeal obstruction, and in whom the disuse 
of the nose on the one hand, and its altered nutrition on the other, have 
been active causative agents in the production of the trouble. 
The nasal septum is composed of three separate parts—the cartilag- 
inous portion, the perpendicular plate of the ethmoid, and the vomer. 
Any of these three parts may be fractured alone or any part of them 
may partake of the injury. Fracture of the septum, therefore, may be 
divided into three parts : first, that of the perpendicular plate of the 
ethmoid; second, fracture of the vomer; and third, that of the septal 
cartilage. 
Fracture of the perpendicular plate is not uncommon, occurring with 
fracture of the bones proper, especially where the fracture is extensive 
or comminuted. It may also be isolated, and in that case is likely to 
be found near the union of the perpendicular plate with the vomer. 
Fracture of the vomer is rare, and not likely to be attended with displace- 
ment. It is therefore difficult to recognize. Injuries to the septal carti- 
lage may be of the nature of dislocation or fracture. The first variety 
is commonly met with and often difficult to remedy. The deformity 
resulting from it is not confined to the interior of the nose, the tip of 
the organ being thrown to one side and much injury done to the facial 
line. The accident is common in children, and is liable to pass unrecog- 
nized on account of the swelling which conceals it. 
Actual fracture of the cartilage is more likely to happen in adult life, 
the cartilage in some individuals showing an early tendency to calcifica- 
tion, which, although not developed to an extreme degree, may be suf- 
ficient to render it comparatively brittle. It is due, of course, to direct 
violence, and this is generally associated with injury to the parts of the 
septum posterior to it. It is sometimes easily recognized and some- 
times not, owing to the fact that few septa are originally straight and by 
reason of the swelling which has taken place. Palpation, rhinoscopic 
examination—if possible, under cocaine—and the use of the nasal probe 
will generally give the necessary aid in recognizing injuries received 
within the nose. 
The fact that there is no external deformity of the nose may not 
prove that extensive injury has not been suffered within. Generally, 
however, the nature of the injury may be inferred by some change in 
its external contour, especially with regard to the tip of the nose, which 
will suggest the real nature of the case. 
The treatment is a matter always requiring a considerable amount 
Fracture of the Nasal Septum. 200 
DISEASES AND INJURIES OF THE RESPIRATORY ORGANS. 
of care, skill, and judgment. In all cases great advantage is gained from 
an examination of the nose before swelling has taken place. 
Dislocation of the cartilage in children is, as a rule, impossible to remedy 
by any known efficient means. Complete luxation having once taken place, the 
base of the cartilage is so loosened that it is impossible to retain it in its normal 
position, and even when it is retained from the earliest period after the accident 
it generally happens that the displacement will recur in spite of treatment having 
been carried on for a long period of time. With older subjects the case is some- 
what easier, and even in children where complete healing of the parts has taken 
place considerable may be done at a period subsequent to the accident by surgical 
means. For the relief of these deformities Asch has attained success by incising 
the cartilage in the lines necessary to relieve the deformity, fracturing it at the 
points necessary to overcome its resiliency, replacing it in the median line, and 
causing the patient to wear for a number of weeks a perforated tube of hard rubber 
made to fit the parts. This tube may be manipulated by the patient after a little 
instruction, and its presence need not be irritating. This operation may be used 
with advantage in cases of deflection extending beyond the cartilage. 
Operations upon the nasal septum are commonly called for and 
extensively practised. They may be divided in general into two 
classes : 
1. Those for the removal of projections in cases where the normal 
thickness of the septum has been increased; 
2. The straightening of deflected septa whose transverse diameter 
has not been materially altered. 
These two varieties of deformity may require widely different treat- 
ment. Projections from the nasal septum may be removed by the use 
of caustics, the cautery, or electrolysis. They may require the use of 
some cutting instrument, such as the saw, the knife, the chisel, or the 
forceps. The use of caustics is mainly applicable to hypertrophy of 
the soft tissues of the septum, and particularly those which occur on the 
anterior and inferior part. The galvanic cautery is of somewhat more 
extensive application on account of its greater destructive power. It 
may be used for the destruction of cartilage and even for bone. Elec- 
trolysis has been used with some success for the removal of small ante- 
rior projections of soft tissue. 
For cartilaginous and osseous spurs other means will generally be 
required, although the electro-cautery is sometimes useful in these. 
Removal of these is best accomplished by some cutting instrument, the 
most popular of which is the simple nasal saw. The latter should be 
specially constructed for the purpose and of the best workmanship. 
The electric trephine, merely a variety of the saw, is often a valuable 
substitute for the latter. Variously constructed knives, scissors, and 
gouges are used either to separate the ridge or to reduce remaining pro- 
jections after the use of other instruments. 
The removal of septal spurs may be accomplished either with local or general 
anaesthesia. Where the operation promises to be severe the latter maybe required. 
In nearly all cases cocaine will suffice. In operating strict aseptic precautions 
should be attempted, notwithstanding the evident difficulty of actually securing 
them in the nasal passages. The patient should be seated and his head firmly sup- 
ported. The nasal cavity, having been cleansed and anaesthetized, should be care- 
fully inspected, and the exact nature, extent, and direction of the proposed incis- 
ion determined upon. In using the saw it is generally more convenient to cut 
from below upward. Everything being ready, the saw should be introduced, the 
line of direction carefully noted, and as little time as possible consumed in cutting 
through the fragment, the operation being guided by means of anterior rhinoscopy, FRACTURE OF THE NASAL SEPTUM. 
201 
and every precaution taken to avoid injuring the neighboring parts. The distal 
end of the saw should always be probe-pointed, to avoid unnecessary injury to the 
membrane of the posterior part of the septum and of the wall of the pharynx, which 
latter, however, the saw should not be allowed to touch. The bony structures hav- 
ing been separated, the detached fragment should be finally separated by a smooth 
incision through the remaining mucous membrane, made either with the knife or 
scissors. In using the trephine the instrument is attached to an electric motor, and 
is applied by the aid of rhinoscopy to the anterior end of the projection. Revolv- 
ing rapidly, it is caused to cut its way through the long diameter of the ridge. 
Where the base of the spur is narrow, its removal may be accomplished with 
one introduction of the trephine. If it is somewhat broad, several such attempts 
may be required. In cases of unusual difficulty, and where the thickness of the 
septum will permit, a large core may be pierced through the longitudinal centre of 
the projection and its final removal accomplished with the nasal saw. Irregularities 
remaining after the use of the trephine should be removed with the aid of some 
suitable instrument. 
Bleeding after operation is not usually severe, and in any case may 
be stopped by tamponing the nose with a narrow continuous strip of 
antiseptic gauze. The use of the tampon is often unnecessary, although, 
as a rule, air should be excluded from the nostril. 
The shock of these operations is often severe. The patient should 
be warned of this, and should be treated with the same consideration, 
as to rest and general attention, as would apply to any other surgical 
condition, even slight operations upon the septum being sometimes 
followed by considerable general disturbance. CHAPTER Y. 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
Edmond Souchon, M. D. 
Congenital Malformations. 
Absence of face is called aprosopia; more or less marked imper- 
fections of the face are called atelo-prosopia. Congenital branchial fistuloe 
have been observed on the face on the line extending from the auditory 
meatus to the labial commissure, and also in the groove between the 
nose and cheek. Congenital atrophy of the face may affect the whole 
face or one side only. In unilateral atrophy the skin is shrunken, 
yellowish, hardened. In sclerema neonatorum the skin is waxy, hard, 
tense, cold; the body lies motionless as if the face and limbs were fixed 
in death; the child cannot open its mouth to suck; the disease occasion- 
ally appears a few days after birth. Albinism is congenital absence of 
pigment in the skin, hair, and eyes. 
Congenital hypertrophy of the face may include the whole face or 
only one side. Double face has been observed on a living subject. 
(Edema neonatorum is very rare in the face; it begins in the lower 
limbs and ascends. Ichthyosis is, as a rule, congenital, although the 
disease is seldom noticed until some little time after birth; it very 
rarely attacks the face. Xeroderma is the commonest form of ich- 
thyosis, and is often nothing more than a dry, scaly condition of the 
skin. The congenital “ scrofulous ” face presents three types. 
In the sanguine type the face is oval; the skin is thin, transparent, the veins 
often showing through ; the complexion oftener dark than fair; the expression is 
bright, sharp, and animated; the eyes are bright, and often dark; the eyelashes 
long, silky; the nose sharp and long, the alae contracted; the lips are thin, the 
teeth are white and often brittle; the lower jaw is small and angular; the hair 
fine and silky, often dark, not over-abundant. In the phlegmatic or melancholic type 
the face is round and plump; the skin is thick, pasty, muddy; the complexion is 
usually fair; the expression is more or less dull, heavy, apathetic; the eyes are 
large and full, usually pale; the nose is large, the alee thick; the nostrils open 
and dilated; the lips are thick, especially the upper; the teeth soon decay; the 
lower jaw is large and broad; the hair generally thick and coarse. In the type 
called pretty struma the coarseness of the features is toned down ; the lips are 
plump, but not tumid; the face, like the body, is plump, but not flabby (Southam). 
Proper and long-continued specific treatment may improve these conditions. 
Congenital syphilitic hypertrophy of the face in children or in young 
adults, presenting evidence of congenital syphilis, is characterized by 
prominence of the frontal eminences, imperfect development and de- 
pression of the bridge of the nose, opacity of the cornea, pits and scars 
on the face and forehead, cicatrices and fissures of the cheeks and at the 
202 CONGENITAL MALFORMA TIONS. 
203 
angles of the mouth, malformations of the permanent teeth, especially 
of the central incisors of the upper jaw (Southam). Long-continued 
proper specific treatment will improve such appearance. 
Birth-marks or port-wine stains are more frequent on the face than anywhere 
else; they may be very small or very large; they may be level with the skin or 
they may be raised. They should be treated as they are in other parts—with 
more care, if possible, on account of the cicatricial marks. 
Congenital deviations of the face, or asymmetries, in which the face 
is thrown to one side, have been observed to a lesser or greater degree. 
Acquired or Post-natal Malformations of the Face.—Atrophy of 
the hair comprises alopecia, which is loss of hair in circumscribed, well- 
defined areas, with a smooth and shining skin. Pigment-atrophy is 
called leucoderma or vitiligo ; it presents patches of blanched skin, and 
is a loss of pigment in small or large areas. Although the neck is the 
most common situation for it, the face may also be affected. Canities is 
the loss of pigment of the hair-shaft. Anidrosis is absence of perspira- 
tion, or dry-face. Atrophy of the cuticle is usually a senile atrophy. 
Atrophy of the whole face or of a side or of a part of it has been 
observed after losses of tissue. 
Facial trophoneurosis, or reflex or paralytic atrophy, is the name given by Shott 
and Romberg to a special atrophy affecting by preference the face, where it always 
remains unilateral: it is due to a lesion of nutrition allied to a functional disturb- 
ance of the nervous system. The cause is unknown : it is not a sclerosis, but an 
absorption of all the tissues, especially of the connective. Hypertrichiosis or hir- 
suties is excessive or abnormal growth of hair, very objectionable in women espe- 
cially. Trichorrhexis nodosa is a nodular condition of the hair. Tinea nodosa is a 
nodular concretion consisting of fungus spores : it weakens the hair, which splits 
and breaks; it sometimes affects the hair of the whiskers, beard, or moustache. 
Pigment hypertrophij is called lentigo, ephilids, or freckles when it assumes the shape 
of a localized deposit of pigment: it is most commonly situated on the face, espe- 
cially about the nose and cheeks; in the pregnant female it is called chloasma ute- 
rinum. It is the ordinary chloasma or liver-spots when presenting a circumscribed 
deposit of pigment, which grows more and more diffuse so as to cover large areas. 
Telangeiectasis is a condition in which the capillaries are considerably dilated over 
a larger or smaller area of the skin : it occurs on the face and neck especially, par- 
ticularly in elderly people, in the form of small spots constituted by small tufts of 
dilated capillaries; the disease resembles the slighter form of vascular ntevus. 
Tinea versicolor is caused by a special fungus : it presents roundish, slightly raised, 
scaly patches, with well-defined borders, a peculiar brownish discoloration; it is 
very rare on the face. A ncevus pigmentosus or mole is a simple deposit of pigment 
with or without raising of the corresponding part of the skin. The bronze face of 
Addison’s disease, dermato-molasma, is a discoloration due to a peculiar condition 
of the suprarenal capsules. Xeroderma pigmentosum, or Kaposi’s disease, is a very 
rare affection: the initial lesions are small pigmentary spots appearing chiefly on 
the face, neck, and arms; they form numerous tumors which run a rapid course and 
end in death. Pityriasis is characterized by a brawny desquamation: it usually 
occupies the hairy parts; it is much more rare on the face than on the scalp. 
Pityriasis rubra pilaris presents at the orifice of the hair-follicles characteristic 
papules; on the face the lesions are often of a seborrhoeic type, a red base being 
covered with adherent crusts. Ichthyosis is rare on the face. A scaly-face skin is 
often met with in old people. Psoriasis consists of flat, dry patches of variable 
size covered with white, silver-gray, or asbestos-like scabs: it rarely affects the 
face, except in young subjects and in inveterate cases. Hyperidrosis is excessive 
sweating: it is sometimes limited to the course of the fifth nerve. Seborrhcea is an 
excessive secretion of sebaceous matter. Seborrhcea oleosa is an excess of oil-like 
secretion. Seborrhcea sicca is excessive secretion of sebaceous matter with excessive 
proliferation of unaltered epithelial cells. Seborrhcea in both forms is more com- 
mon on the scalp, but the eyebrows, moustache, and beard are sometimes the seat 204 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
of dry seborrhcea. On the face the oily form is more frequent, affecting especially 
the middle third of the face, usually the alae of the nose and naso-labial groove; 
also the corners of the mouth and the ears. Seborrhoea most invariably begins on 
the scalp ; then it spreads on the face to the eyelashes. Dermatolysis is the hyper- 
trophy of the integuments and subcutaneous tissues, which are all loose, pliable, 
feeling like fatty tissue: it is an exaggerated form of molluscum fibrosum, 
marked by large flaps or folds of hypertrophied skin ; their commonest site is 
about the neck, face, buttocks, and chest; the flaps are often deeply pigmented, 
thickened, indurated, and warty; hypertrophy of the bones and other subjacent 
tissues may also be present. Rhinoscleroma is peculiar to the nostrils and to the 
skin around them : it begins by nodules in the cutis, which coalesce to form a hard 
growth with a smooth glistening surface, which spreads inward from the lip and 
downward to the pharynx from the posterior nares; it is a rare affection. Sclero- 
derma is a diffused thickening and hardening of the skin; the skin is rigid, 
tense, hard like that of a frozen corpse, but without the coldness; the features are 
drawn and the face becomes fixed into an expressionless mask. In atrophic 
scleroderma the skin shrinks and becomes waxy-white in color; the face and 
upper limbs are the only parts attacked. Leucoderma is a similar condition, but 
without hardening of the integuments. Morphcea is a circumscribed scleroderma, 
lardaceous in appearance, mottled, with pink areoles; the lesions vary in size from 
half an inch to the palm of the hand ; the patches on the face sometimes follow 
the coui’se of the fifth pair. Morphcea is also called Addison’s keloid. The face is 
a favorite site for it; it presents well-defined waxy patches of a pale pink and yel- 
low color; it is due to some vasomotor disturbances. White keloid is a kind of 
scleroderma, not true keloid. The keloid of Adihert is a different disease, which 
develops spontaneously on cicatrices, especially on burns. Scars on the face grow 
with the body in the course of time. Neurotic or neuralgic hypertrophy is due to 
persistent neuralgia, usually affecting one side of the face only: all the tissues, 
even the bones, participate in it. Acute circumscribed oedema arises suddenly and 
subsides rapidly, only to develop in another part: its favorite seat is the face and 
the genitals. Frog-face is due to intranasal tumors, which, growing toward the 
face, raise and spread the nose and the surrounding structures. Elephantiasis \ne- 
sents the characteristic “ leonine face: ” it is the tubercular and mixed varieties 
which have a predilection for the face, nose, lips, cheeks, eyelids, chin, ears. The 
affected skin, especially in the nodular stage, is often the seat of seborrhoea; 
this gives the nodules, particularly on the face, a characteristic burnished appear- 
ance. The hair in the affected areas fall out. In the vast majority of cases of 
nodular leprosy the ends of the ears are the first parts affected. Elephantiasis 
Arabum is a chronic hypertrophy of the skin and subcutaneous tissues: it affects 
the face rarely. In the infiltrated form the face is affected after the limbs. 
Acromegaly affects also the face, including the soft and the bony structures. 
Myxoedema is a hard swelling of the face and neck and of the extremities: it 
is also called cachexia strumipriva, cretinoid condition, thyreopexa. It is a rare 
disease. Myxoedema and cretinism are totally different diseases. It is due to some 
destructive changes, such as fibroid degeneration, interstitial hyperplasia of the 
connective tissue, syphilis, atrophy of the glands; to the removal of the whole 
of the thyroid; in some operated cases it is due to the atrophy of that portion 
of the body which had been left on purpose. The anatomo-pathological lesions 
are hyperplasia of the connective tissue of the face and neck and extremities; 
the connective tissue is increased in quantity and density; there is excess of 
mucin in the skin and in the blood; haemoglobin is diminished; the red blood- 
corpuscles and the fibrin vary. The power of the red blood-corpuscles to take up 
oxygen may or may not be deficient. The anaemia of myxoedema is said to be due 
to the suppression of the hsemopoietic functions, to alteration of the regulation of 
the cerebral circulation, to the loss of function of the thyroid, which is an organ 
of depuration and elimination. 
The symptoms are—the skin of the face, neck, and later of the extremities, is 
swollen in a characteristic manner; the speech, the motions, the intellect, all the 
mental and bodily functions, decline; in young subjects mental development is 
arrested. Its course is slow; it is always progressive, without any halt or im- 
provement. Its duration extends usually over a year. Its termination is 
death. 
The preventive treatment consists in leaving a piece of the thyroid body in A CQ UIBED MA L FORMA TIONS. 
205 
all cases of total extirpation of the organ. The curative treatment consists in giv- 
ing thyroid extract by mouth, by hypodermic injection, or by grafting a piece of 
the thyroid body of an animal into some part of the patient’s* body. 
Acquired Deviations of the Pace.—Mutilations are on record in 
which one side of the face is natural, and the other drawn so as to 
present the expression of perpetual laughter, as depicted in Hugo’s 
“ L’ Homme qui Hit.” 
Injuries of the face would be still more frequent than they are, on 
account of its exposed position, but for the small size, excessive mobil- 
ity of the head, and the protection afforded by the arm and forearm 
instinctively brought up quickly in front of the face. 
Burns are usually deeper than they seem at first: they are often 
followed, in the mildest forms, by at least coarseness of features, ugly 
cicatrices, and deviations, whose result is dribbling of the saliva: the 
cicatrices sometimes interfere with the movements of the lower jaw. 
It is important to prevent the patient from scratching himself during 
sleep or delirium, so as to prevent a frequent and potent cause of 
increasing the deformities. Burns by acids, striking the face accident- 
ally or by a criminal hand, are the most frequent of the kind ; in crim- 
inal cases it is the face that is specially aimed at; on account of the 
disfigurements that follow and of the loss of the sight these burns are 
of the gravest character. No special treatment is here required except 
greater diligence. 
Freezing or frost-bite is common about the face on account of its 
exposed position. Reaction should be brought about very slowly, so as 
to limit the damage and leave as little cicatrix as possible. When 
blebs form, it is of bad omen. There often remains after recovery a 
purple color, for which subcutaneous injections of ergotin have been 
recommended. 
Contusions are often followed by great swelling and discoloration, 
especially about the eyelids (black-eye): they are specially frequent in 
children, who have so many falls; they affect especially the prominent 
parts. When the injury is located over a bone, there is formation of 
a lisematoma; when in soft regions, the blood becomes infiltrated. 
Contused and lacerated wounds often present a lesion of the deep 
much greater than of the superficial parts, as it is the underlying bone 
that has done the cutting. 
Contused wounds produced from without are the most frequent; 
sometimes they are very extensive, such as a result of the kick of a 
horse, terrific falls, etc., and large portions of the facial mask are torn 
away and hang down. Deep sutures can be placed to advantage to 
support and approximate the parts. 
Punctured wounds, when deep, are apt to be followed by subcu- 
taneous hemorrhage: they may penetrate one of the cavities, where the 
weapon may be broken, as in the maxillary sinus, orbit, cranium. 
Incised wounds usually gape much : very often fatty lobules pro- 
trude between the edges of the wound. Sabre wounds sometimes carry 
away the whole of projecting parts ; they bleed freely. Great care should 
be taken to approximate the edges properly, so as to avoid unsightly 
cicatrices : fine needles should be used, also fine silk; plaster strips or 
collodion should be placed over them. These wounds unite generally 206 
SURGICAL DISEASES ANI) INJURIES OF THE FACE. 
by first intention, because the skin, subcutaneous tissue, and muscles 
form but a single matted layer or structure. 
Gunpowder dams should be removed at once and thoroughly : if they 
are allowed to remain, they will remain for life. If necessary, cocaine 
or an anaesthetic must be used; the parts should be first scrubbed with 
a hard nail-brush ; then all the grains of powder must be picked out, one 
by one, employing a cataract needle; a 1 per cent, solution of mercuric 
chloride will facilitate the removal of the grains of powder. 
Gunshot wounds of the soft parts of the face alone are very rare. 
There exists a case on record of perforation of both cheeks by a bullet 
without injury to the bones or teeth in an officer who was wounded 
when uttering an enthusiastic hurrah. Gunshot wounds from a distance 
are the rule in war, and may be terrific: in one case the whole face was 
destroyed except the eyes, and the patient survived, feeding through a 
tube which he introduced in the oesophagus. Gunshot wounds at close 
range are most commonly due to suicidal efforts. Such wounds may 
be complicated by the lodgement of a ball or other foreign body in any 
one of the cavities of the face; by the lesion of some organ or nerve of 
special sense; by fracture of the base of the skull; by injury to sali- 
vary glands, teeth, lachrymal glands. Besides, the softness of the bones 
allows the missiles to penetrate deeply and the tissues to contract over 
them ; hence arises great difficulty in removing them. 
Arrow wounds produce great bleeding; all the above remarks concerning gun- 
shot wounds are applicable to them. 
The immediate complications of the wounds of the face are emphysema, due to 
fracture of nasal fossae or maxillary sinuses; wounds of Stenson’s duct; cerebral 
contusion : this is not very frequent nor severe; it is, on the contrary, remarkable 
how few cerebral symptoms develop after violent injuries of the face; this is due 
to the fact that the bones are soft and yield readily. Wounds of the deep arteries 
give rise to hemorrhage through the mouth, without our being able to ascertain 
positively whence the blood comes. The secondary complications are oedema of 
tongue and pharynx, interfering with deglutition, cephalic tetanus, persistent neur- 
algias, cramps, and contractures. 
Secondary hemorrhages are frequent in lacerated and gunshot wounds of the 
face ; they usually take place between the fifth and the twenty-fifth day: it is the 
small deep vessels that are the troublesome factors. No styptics should be used, 
especially here: it is preferable to use methodical plugging with long narrow 
strips that are well packed in small segments in all the nooks and corners with as 
hard a compression bandage as the patient can stand. The bleeding arteries 
should be ligated in situ if possible, but this is very difficult, and often unsatis- 
factory on account of the inflamed and sloughing condition of the tissues. By 
applying a provisional loop ligature around the common carotid the hemorrhage- 
may be controlled until a thorough search and a satisfactory ligature of the bleed- 
ing points be accomplished in situ, when the provisional ligature is removed. In 
such cases the common carotid should be exposed close to its bifurcation, so that 
if the above procedure should fail, the external carotid is within easy reach. It 
might be well borne in mind that it is the external carotid that must then be 
ligated, not the common carotid, on account of possible cerebral complications. 
In extensive or general bleeding it may be necessary to ligate both external 
carotids: in such an emergency the ligations should be applied above the origin 
of the linguals. 
The sequels of injuries of the face are reflex contractions of the muscle of the 
face from a wound of the face or scalp, constrictions of the jaws, ectropion of the 
lids or lips, atresia of the mouth. These injuries are sometimes followed by 
amaurosis, especially if they occur near the orbit or the malar bone; the lesion is 
often a dislocation of the lens or a detachment of the retina; sometimes there is 
no detectable lesion. NEUROSES OF THE FACE. 
207 
Mortality of injuries of the face is comparatively low, because the vessels and 
the bones are small, the bones are thin, the parts naturally drain well through the 
nose and mouth, and the vascularity and the nutritive powers are here at their 
best. During the War of Secession 90 per cent, recovered, some with horrible 
mutilations. 
Fractures of the nose are treated elsewhere. (Vide Vol. I.) 
Poisoned wounds, stings of bisects, of spiders, etc. are common, be- 
cause of the exposed condition of the face ; the swelling spreads rapidly 
and is particularly disfiguring. In cases of bites of horses or of dogs 
there is a flap corresponding to the upper jaw of the animal and one of 
the lower jaw. Bites of rabid animals are much more rapidly followed 
by hydrophobia, because the distance to the brain is so much shorter 
than when the hand or any other part is the site of the injury; also 
because, the teeth penetrating at once into the tissues without passing 
through any clothing, the inoculation is more thorough and more viru- 
lent. All poisoned wounds of the face should be treated as in other 
regions. 
Neuroses of the Pace.—Anaesthesia of the skin of the face is usually 
due to the paralysis of the trifacial; it is a symptom of a lesion of the 
nerve-centres. Double paralysis of the face is called diplegia. Facial 
paralysis, or Bell’s palsy, is usually caused by brain lesions, but may be 
due to the effects of cold on the nerve, of blows, of wounds or operations 
injuring the nerve in some point of its course or at its point of emer- 
gence ; diseases of the temporal bones (fractures or caries), or otorrhoea. 
Its peculiar symptoms are inability to close the eye, prolapse of the cheek, 
eversion of the lower lip, the deviation of the face toward the sound side. 
When the patient laughs, the expression of the whole face is most peculiar 
and characteristic. The treatment varies with the cause. Facial hyper- 
cesthesia comprises dermatalgia, or painful skin, or pruritus or itching, 
especially of the skin of the beard or of the nares; it is rather rare. 
Facial neuralgia is called tic douloureux when the pain is accompanied 
by contraction of the muscles; its special cause here is often a carious 
tooth, although the tooth itself may be painless; the other causes are 
painful cicatrices, foreign bodies, callus including a nerve, tumors, 
inflammations, diseases of the petrous bone or intracranial tumors. Its 
special treatment in obstinate cases is the stretching or the section of the 
nerves at their points of emergence (neurotomy and neurectomy) or the 
removal of the Gasserian ganglion. Facial spasm, or convulsive tic with- 
out pain, is a clonic spasm causing contortions of the side of the face: 
it ceases during sleep. Cephalic hydrophobic tetanus may result from 
a bite of a non-rabid animal; it affects the course of a cranial nerve; 
the facial nerve is paralyzed on the side of the wound. The symptoms 
are those of hydrophobia; the face is congested and haggard. 
Chromidrosis and purpura are mentioned here for want of a better place. Chro- 
midrosis is a colored secretion of the sweat and sebaceous fluids, usually blue in 
color, or red, yellow, green, or violet: it is usually symmetrical; its favorite site is 
the eyelids, next the cheeks, the forehead, the sides of the nose, sometimes the 
whole face and the body. Purpura is the extravasation of blood in the cutis; it 
is rare in the face compared with the other parts of the body; it is there most 
commonly situated in the eyelids. The treatment must be general and directed 
to the blood. 
Furuncles or boils most frequently affect the face and neck. Car- 208 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
buncles of the face are comparatively rare and nearly always fatal. 
These lesions are particularly grave about the face, because of the 
septic absorption by the facial vein and its direct conveyance to the 
sinuses of the brain. Carbuncles should be freely incised or curetted at 
the very outset. Erysipelas is common : it is usually due to some lesion 
in the interior cavities, buccal, nasal, pharyngeal, Eustachian tube 
or external auditory canal; it emerges from the tip of the nose or 
from the lachrymal points or from the external auditory canal. 
When it first travels through the Eustachian tube and the middle 
ear it is preceded for two or three days by most agonizing pains: 
it is more serious here than anywhere else, because of the propaga- 
tion to the brain and membranes. It seldom stops until it has gone 
over the whole face and head, seldom extending beyond the neck 
to the trunk: it usually leaves the features coarser than before its 
advent. Of course the interior cause must receive proper attention dur- 
ing the attack, and also afterward in order to prevent a return: it 
requires here no particular treatment. Erysipelas of the face is some- 
times complicated with pericarditis, myocarditis, and oftener with endo- 
carditis (Gubler). 
Malignant pustule is also comparatively frequent, for the reason of easy access 
to the face: it is more fatal here because the radical means of treatment are not so 
easily applied as on the hands; also because of the close proximity of the brain 
and its sinuses. Glanders shows externally first by an inflamed and ulcerated con- 
dition of the nostrils and upper lip. Cellulitis is rare, because of the adhesion of 
the skin to the muscles and of these to the bones. Congestions of the face do not 
spread easily for the same reasons. But septic inflammations are often followed by 
much swelling, oedema, and hardness. They should be treated as in other regions. 
Cellulitis and abscesses of face are usually due to diseased teeth or to osteoperiostitis 
of the jaws. Abscesses are also comparatively rare: most frequently they originate 
from the root of a decayed tooth. Abscesses of the face should be incised with the 
greatest care, bearing in mind the direction of the folds or wrinkles of the vessels, 
the nerves, Stenson’s duct,—all this on account of the scar that may follow; for these 
reasons it is often best when circumstances permit to let them open for themselves, 
when the scar is reduced to a small round white spot less noticeable than a cut. 
Phlebitis of the facial vein is rarely primary: it usually follows other inflammations 
of the face, especially furuncles and carbuncles, and particularly those of the 
upper lip. It is characterized by rapid swelling, with oedema, intense pain, sen- 
sation of strangulation; the face is earthy pale, the course of the veins marked by 
blue lines. 
Gangrene of the Face.— Gangrene of the face is rarely primary : it 
is usually due to injuries, to carbuncles, to malignant pustules. Can- 
crum oris, or noma, is peculiar to the cheeks. Great care is neces- 
sary to limit the following deformity as much as possible. Raynaud’s 
disease is symmetrical gangrene of the extremities, including in this 
term the tip of the nose and the ears: the order of frequency is the 
fingers, toes, heels, nose, ears. 
Ulcers of the face may be due to many causes. Tubercular ulcers 
are the most frequent outside of syphilis ; they are called lupus, and the 
face is their favorite site. Lupus erythematosus is not tubercular. 
Lupus non-exedens is characterized by an eruption of pale or reddish 
tubercles which ulcerate, become covered with white scales and scabs, 
which on coming away leave behind a smooth white depressed cicatrix. 
Lupus exedens destroys by ulceration; lupus non-exedens destroys by 
atrophy. FORMS OF ULCER OF THE FACE. 
209 
The favorite site of lupus is the face. Lupus vulgaris, or malignant herpes, is 
also a form of tubercle of the skin due to the bacillus: it appears as small tumors 
on the skin, especially on the forehead, cheeks, and nose; the lesions are grouped 
tubercles of apple-jelly color and consistency, smooth, tending to ulceration. It is 
more grave; it resembles epithelioma, but is less painful; the edges are not as hard 
and elevated ; the favorite site of lupus is the face, especially the nose and the neigh- 
boring part of the cheeks. Nodular lupus presents more or less localized nodules, 
tubercles, and nests, reddish or yellowish pink; often quasi-gelatinous; it usually 
attacks the cheeks near the junction of the alse and the upper lip. Diffused lupus 
is superficial, less inclined to form nodules and nests: affects the cheeks and nose most 
frequently. Lupus seborrhceicus (Volkmann) presents irregular nodular patches on 
the cheeks and nose, covered with dirty-looking skin, crusts fatty to the touch: 
after partially scraping off the scab the underlying skin appears red, sore, as if 
studded with fine warts; but when examined with a lens are seen a number of fine 
holes, which are the enlarged openings of the sebaceous ducts: each single fatty 
crust has a fine prolongation of the latter, which becomes detached from each 
opening. 
Ulcers of the face which resist ordinary treatment should be cocain- 
ized and curetted; if necessary they should be extirpated like cancers. 
The Biskra button or Aleppo boil is a tropical disease beginning by a 
boil which leaves a foul ulcer : it is due to a micro-organism. Syphilitic 
ulcers are common in all their forms and varieties—papular, tubercular, 
rupial, etc. General specific treatment is indispensable. 
Indurated chancres may occupy any part, but they are more rare than 
around the mouth; they are sometimes two or three in number; they 
are usually accompanied by a hard and purple oedema, with greater 
nodular engorgement than in other situations. Chancroids or soft 
chancres of the face have been observed, but are very rare. Tertiary 
syphilitic ulcers are tuberciilo-ulcers and resemble lupus : they often pre- 
sent here a rapid evolution, and are rebellious to specific treatment, 
destroying soft parts and bones alike, followed by destruction of nose, 
and cicatrices, causing atresia and ectropion of the natural orifices. 
Yaws, or framboesia, presents reddish papules, tubercles, or tumors 
studded with yellow points, which ulcerate: it is a very rare disease. 
It may appear first on the lip; sometimes the papules are arranged in 
rings, especially round the eye, nose, mouth, and the genitals. Tertiary 
ulcers of yaws are also common about the lips. 
Cancerous ulcers are limited usually to the skin ; however, cancers on 
the deeper tissues, and especially the bones, finally ulcerate. Cancers 
commencing on the skin are the squamous epithelioma and the rodent 
ulcer. Rodent ulcer is a form of epithelioma: it is remarkable that 
almost every case of rodent ulcer has its seat within an area bounded by 
a line drawn from the uppermost point of the pinna to the root of the 
nose, and another drawn from the lobule of the ear to the columella of 
the nose. It exceptionally occurs on the hands. It must be thoroughly 
curetted or destroyed by pastes or extirpated. (Vide Vol. I. p. 429, 
Figs. 177, 178.) 
Epithelioma is the most common of all cancerous affections of the 
face, which is a favorite site for it. It is important to remember its 
forms and varieties—superficial or flat epithelioma, presenting scales or 
a grouping of papules or an inflamed sebaceous outlet; the indurated 
or circumscribed; the papillary; the infiltrated or diffused, which 
resembles the condition of chronic inflammation : sometimes it begins 
by separate spots which coalesce; there is no elevation of the diseased 210 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
parts. Epithelioma of the face when small should be curetted or 
attacked with pastes, but when of size or deep, extirpation is the best 
remedy : early interference is most desirable to avoid large scars. 
In operating, grafting and plastic operations must be resorted to to reduce the 
cicatrices and deformities to a minimum. The lymphatic nodes receiving the 
lymphatics from the infected parts should be removed if in the least indurated: 
because of the neglect of this it is common for the disease to show on the parotid 
region or the submaxillary, requiring there much more dangerous and extensive 
operations for the eradication of the disease. 
Fistulse of the Face.—Fistulse of the face are not very common: 
they may be congenital—e. <j. of branchial origin; they may be lach- 
rymal or salivary, or due to an incised cyst which does not heal, to a 
carious tooth, or to a diseased bone. One of their peculiarities is the 
scar that follows their healing, and which most commonly tells of a 
disease of the bone. 
Scrofuloderma of the Face.—Scrofuloderma is the general name for 
all diseases of the skin of a strumous or scrofulous nature. We must 
bear in mind that scrofula is a particular constitutional state in which 
bacilli, especially tubercle bacilli, readily flourish, but not tubercles alone ; 
the lesions in scrofulous subjects are apt to take on a character of chronic 
inflammation of a peculiar type, in which a tendency to suppuration and 
formation of unhealthy sores is the most marked feature. 
Lichen scrofuloderma is a papular eruption, the elements of which are not 
larger than a pin’s head, are flattened, and are very slightly resistant; it is very 
rare on the face. Erythema induratum scrofulosum is formed of chronic inflam- 
matory, deep-seated nodules; it is rare on the face. 
Strumous dermic gummata, or scrofulo-tuberculosis or attenuated tubercu- 
losis, are characterized by a tendency toward caseation and the formation of a cold 
abscess. Strumous ulcers are due to the extension of the inflammatory process 
from caseating lymphatic nodes to the skin covering them, or to the formation of 
a nodule or circumscribed induration under the skin, or to extensions from bone 
which is the seat of tubercular osteomyelitis: they are common on the face and 
on the hands. 
Tuberculoderma of the Pace.—Tubercular ulcers, due to primary 
tuberculosis of the skin, are ulcers with infiltrated, ragged, and 
undermined edges, and a slightly indurated floor covered with yellowish 
tubercles moistened with a thin and scanty secretion : they may occur 
on the face, on the head, and elsewhere. They are sometimes due to 
breaking down of small tubercular nodes preceding or following pul- 
monary or intestinal tuberculosis. They are generally situated at the 
junction of the skin and mucous membrane, about the corners of the 
month and margin of the nares, especially in cases of lung disease. 
The treatment of these diseases lias already been described. 
Syphiloderma of the Face.—Syphiloderma includes all the diseases 
of the skin of syphilitic origin. Primary sores or chancres have 
already been mentioned above: they may occur on the lips, cheeks, 
tongue, from smoking infected pipes, from using infected glasses, forks, 
spoons; from kissing; from dentists’ instruments; from unnatural 
practices. Of the secondary manifestations the eruptions atfect usually 
the face last: they may be papular, tubercular with or without ulcera- 
tion ; rupia or alopecia of beard, eyebrows, eyelashes. Small papules 
may form a kind of circlet on the brow round the margin of the hair TUMORS OF THE FACE. 
211 
(corona veneris). The more common position of tertiary syphilitic 
lesions is the forehead and the margin of the scalp. In congenital 
syphilis the face sometimes presents a senile aspect. Tertiary ulcers 
have already been mentioned above. 
The treatment must be practically general and specific. 
Actinomycosis of the face has been observed under the form of 
tubercles, hard, movable, indolent, soon forming abscesses, and then 
ulcers: it is distinguished from all other similar lesions by the special 
parasite. 
Tumors of the Pace.—Some tumors of the face originate from the 
spheno-maxillary fossa and become superficial on the cheek. 
Of the gaseous tumors we will mention here emphysema of the face, due to frac- 
tures and dislocation of the nasal, lachrymal, and superior maxillary bones or to 
rupture of the nasal mucous membrane, with penetration of air into the tissues; 
it calls for prompt reposition of the bones and pressure to prevent the spreading 
of the disease to the neck and larynx. 
To the fluid tumors (blood, serum, pus) the following points of peculiar in- 
terest apply: Liquid hcernatomata should not be punctured nor incised, but 
should be aspirated in time if they resist compression. Aneurisms of the face are 
rare: they are usually traumatic. A lymphatic nodule raised by the facial artery 
may be mistaken for an aneurism. Edasis of the facial vein has been observed 
once near the commissure. Angeioma or erectile tumor or ncevus of all kinds from 
the birth-mark to the venous and arterial, from the small or limited to the broad 
and diffused, is rather common on the face. The same means should be employed 
here as elsewhere, bearing in mind the cicatrix and deformity that will follow. 
Lymphangeioma circumscriptum cutis is characterized by the formation of vesicles, 
forming patches of greater or lesser extent: they have been found on the face, 
limbs, neck, and shoulders. The essential features of the condition are overgrowth 
and dilatation of the lymphatic vessels; they should be curetted or extirpated. 
Lymphangeioma of the face is frequent: the face is its site of 
predilection. It is always congenital: it corresponds to what is called 
congenital hypertrophy, and may be limited to one region; when 
incised the lymph runs out. Macromelia is congenital hypertrophy of 
the cheek. Cystic lymphangeioma resembles serous multilocular cysts of 
the neck : the cheek is raised by a tumor of variable size, almost round, 
limited or diffuse, lobulated, with ill-defined fluctuation; it may extend 
under the zyomatic arch. Upon a superficial examination it resembles 
oedema, but by palpation isolated hard nodules are felt. Cysts of the face 
are serous and multilocular, branchial, sebaceous, sudoriparous, salivary. 
Hydatid cysts are very rare, but exist: they are not usually diagnosed 
unless punctured. Sometimes the puncture cures them: it is well, 
therefore, to wait before extirpating them. 
Solid tumors, not elsewhere considered, present the following 
varieties: 
Milium is a white and pearly mass of the size of a millet-seed, due to an 
accumulation of sebaceous matter in the duct of the gland, not in the gland itself. 
Milium is seen most frequently on the face, especially on the cheeks, eyelids, 
temple, and forehead. On the eyelids these swellings coalesce, forming flat 
masses which are sometimes so hard as to deserve the name of cutaneous calculi. 
A variety found on the face presents under the form of tiny disks with a minute, 
slightly depressed puncture in the centre, suggesting a fatty degeneration of the 
epithelium around a follicle. Colloid milium, or colloid degeneration of the skin, is 
rare : it presents small yellow, translucent, cyst-like formations containing a gelat- 
inous substance. They affect chiefly the upper part of the face. Comedones are 
pimples with a black spot in the centre: when squeezed, sebaceous matter oozes 
out that resembles a black worm. They are most frequent on the face about the 212 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
nose, the cheeks, and the forehead. When very numerous they produce an 
appearance like grains of gunpowder imbedded in the skin ; when squeezed out 
they look not unlike small maggots. A parasite, the dermodex or acarus follicu- 
lorum, is sometimes found in comedones. Grouped comedones have for a favorite 
situation the flush area of the face, and they form symmetrical groups of black 
points smaller than the ordinary comedones. Xanthoma is formed of plates or 
nodosities of a yellow or yellowish-white color imbedded in the corium: it 
presents the flat or planum and the nodular or tuberosum varieties. Xanthomata 
are most frequent on the face near the eyelids ; they are symmetrical; they look 
like a circle of wash-leather set into the lids. Xanthoma diabeticorum differs from 
the above by presenting a raised red area around the yellow spots; it resembles 
acne; it seldom affects the face. Noevus pilaris is a hair-mole. Acanthosis nigricans 
is a peculiar pigmented condition of the skin with warty growths : in the few cases 
on record the pigmentation has occurred more or less suddenly. The face is first 
affected, then the neck, etc. 
Molluscum sebaceum is a projecting tumor formed by a dilatation of the seba- 
ceous gland, due to the accumulation of the secretion inside of it. Molluscum con- 
tagiosum is a small pedunculated or sessile growth, from the size of a pin’s head to 
that of a pea, with an open orifice, giving exit to sebaceous matter upon squeezing 
it. It is due to the hypertrophy of the gland, not to retention of the secretion : it 
seldom attains a large size on the face. A variety is formed of small growths like 
tiny mother-of-pearl shirt-buttons, with a central depression and a hole leading to 
the tumor: at first they are sessile, but become pedunculated. They are most 
common on the face, the eyelids being a favorite situation. Molluscum epitheliale 
is a tumor-like hypertrophy of the epidermis, umbilicated, pearly-looking, sessile, 
varying in size from a pin’s bead to that of a split pea. The lesions are usually 
grouped and multiple; they are considered contagious; they affect especially the 
eyelids at the inner angles. 
Callosities are rare. Horny excrescences have here a site of predilec- 
tion. Papillomata or warts may be small or large: this affects their 
mode of treatment. They present the following varieties : the vulgar, 
plane, filiform, digital, acuminated, sessile, pediculated. Flat warts 
(verruca plana) in young persons are most common in the face, particu- 
larly the forehead. Verruca seborrhoeica, or seborrhceic wart, consists in 
multiple patches of warty growths; the face is rarely attacked ; it is 
most common in old people. 
Hcemafomata containing clotted blood, usually following injuries and resisting 
compression and aspiration, should be incised with as small an opening as possible, 
on account of the cicatrix. They are most commonly seen on the face; the eye- 
lids are their favorite situation. Hsematomata formed of solidified fibrin, result- 
ing from blows or cured aneurisms, are extremely rare. 
Sebaceous cysts, or steatomata, are most commonly seen on the face 
near the scalp ; usually their dissection here is more difficult than might 
be thought at first. Dermoid cysts may occur on the face occasionally ; 
they are sometimes very numerous and resemble fibromata, but on cut- 
ting into them a sebaceous-looking material escapes. Adenoma (seba- 
ceous) occurs chiefly on the face : it consists of small, firm, whitish or 
yellowish, solid tumors firmly imbedded in the skin at different depths 
or projecting from it. These are sometimes grouped about the end of 
the nose; they vary from the size of a pin’s head to that of a pea; they 
are sometimes red, owing to the dilatation of the capillary veins on their 
surface; the lesions are usually symmetrical, and, though thickly 
crowded together, they do not run together to form patches. They 
present no opening: when pinched inspissated sebum can be squeezed 
out of them. They are usually congenital, though further crops of lesions 
appear after birth, especially at puberty ; they undergo little change. TUMORS OF THE FACE. 
213 
Telangeiectasis, acne rosacea, warts, mevi, keratosis pilaris, etc. often 
coexist with adenoma sebaceum; the patients are usually of a low grade 
of mental development. 
Epithelioma adenoides cysticum is formed by small tumors which become shining 
and translucent, containing one or more minute white, brightly-refracting milium- 
like bodies: they are firm, but not hard, and can be felt imbedded in the skin. 
The most common sites are the space between the eyebrows, the root of the nose, 
the nostrils, the cheeks, the upper lip, and, to a less extent, the chin : they are so 
thickly clustered together as to form disfiguring lumpy patches; they may occur 
on other parts of the body. 
Syphilitic gumma, and diffused syphiloma of the face exist and re- 
semble leprosy; they usually follow syphilis of the lip. Lipomata are 
not often met with on the face: they are usually small and numerous, 
as in all situations where the bones are superficial; they are sometimes 
congenital. Branchial jibro-chondromata, also called auricular append- 
ages, supernumerary auricles, congenital appendices of the face, are 
not very rare: they are congenital. Their surface is formed of skin: 
in the centre is often found a cartilaginous stem; they are most common 
in front of the tragus or on it, but they are also seen in all the regions 
of the branchial arches ; also on the cheek on a line joining the external 
auditory canal to the labial commissure or below the line—in one case 
on the lower lip under the mucous membrane. They are excessively 
rare in the other regions of the face. They may be symmetrical; 
are about one-third of an inch long; are conical or club-shaped or 
pediculated; in the pre-auricular regions they are often multiple, and 
arranged in pairs along a vertical line, and may be symmetrical. After 
birth they seem to increase, and then they remain stationary; sometimes 
they are associated with branchial fistulae. Fibroma of the skin, or fibroma 
molluscum, presents pear-shaped or roundish tumors covered by smooth 
skin, usually pediculated, but sometimes sessile: it is commonest on 
the face next to the trunk. Diffuse fibroma is a molluscum in which 
the tumors are large and attached by broad bases : they are usually mul- 
tiple and overlap each other, forming folds of loose skin with dilated 
sebaceous follicles. Hard fibroma, or neuro-fibroma, is rare on the face, 
in size varying from a pin’s head to large dimensions. Large hard 
fibroma is rare outside of the maxilla. Keloid, is most common after 
burns. Addison’s keloid is not a keloid proper, but a form of morphoea; 
the keloid of Adibert develops spontaneously on cicatrices, especially on 
burns. Do not extirpate a growing keloid. Neuromata are very rare. 
Myxomata, myomata, may all occur on the face, but very rarely. Myx- 
cedema may be regarded as diffused myoma. Osteomata of the malar 
bone are occasionally met with. Encephaloid is rare on the face outside 
of the bones. Sarcoma of the skin, according to Baker, is the most fre- 
quent source of sarcoma, but Kaposi says that in the majority of cases 
the process in the skin is secondary to growths arising in the lymphatic 
nodes or the deeper structures. Sarcoma of the face is sometimes con- 
genital. The melanotic form of cancer is relatively frequent on the 
face : it often follows ordinary angeioma or pigmentary nsevi. Still, sar- 
coma of the face is rare outside of the bones. 
Mycosisfungoides is a malignant neoplasm of the verrueose type: it is rare on 
the face. Kaposi’s disease, or xeroderma pigmentosum, is extremely rare; it con- 
sists of numerous tumors which run a malignant course, and after extensive 214 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
destruction of the tissues cause death by exhaustion. The initial lesions are small 
pigmented spots which resemble freckles, that appear chiefly on the face, neck, and 
arms. 
Operations of the Face as a Whole. 
One of the points of importance about operations on the face is to 
endeavor to leave as little disfiguring scar as possible. 
Operations on the Branches of the Fifth Pair in Cases of Invet- 
erate Neuralgia.—Neurotomy, or section of the frontal nerves at the 
point of emergence at the supraorbital foramen, of the superior maxil- 
lary at the infraorbital foramen, and of the inferior dental at the mental 
foramen, affords only temporary relief. ( Vide also p. 122.) 
Neurectomy, or resection of a portion of these nerves as far as they 
can be traced in the canals and grooves that lodge them, gives more dur- 
able relief, but many cases recur. The inferior dental nerve is more 
thoroughly exposed by trephining through the outer table of the lower 
maxilla along the course of the inferior dental canal. 
Resection of the branches from the Gasserian ganglion, or of the 
ganglion itself without the motor root, gives more permanent relief than 
any other course, but it is a very grave operation. 
In Rose’s method the ascending ramus of the lower maxilla is resected, 
the pterygo-maxillary fossa is entered, the petrous bone is trephined at 
or near the oval foramen, and thus the ganglion is reached. 
In Hartley’s method, or the Krause-Hartley’s method, a large osteo- 
cutaneous flap is cut out in the temporal region ; the dura mater is raised 
from the petrous bone to expose the ganglion, which is removed without 
injuring the motor root. 
Ulcers of the face, when small, should be cocainized and curetted or 
removed with the knife. When the surface is deemed rather large and 
a marked scar apprehended, the spot should be grafted at once. When 
the surface is decidedly large, it is best to perform a plastic operation by 
the sliding process or by the pediculated flap when possible. 
Extirpation of tumors should always be done from the interior of the 
mouth when possible: although more difficult, the advantage is that 
there is no external scar; when the tumors are small and the operation 
aseptic there scarcely should be a scar left. 
Ligation of the external carotid on one side or on both sides will often 
give relief and temporarily arrest the growth of the tumor. If the two 
arteries are ligated, the ligations should be applied above the linguals. 
When the tumor is large and its removal compels that of a portion of the 
skin, the spot should be grafted or a plastic operation resorted to at once 
to close the solution of continuity. 
In making incisions about the face care should be taken to make them 
in a direction that will spare the vessels, the nerves, and Stenson’s duct; 
in one that will leave a less noticeable scar by following, when possible, 
the natural folds, grooves, and wrinkles of the face; bv using thorough 
asepsis; a sharp thin-bladed knife; stopping hemorrhage thoroughly 
before stitching, so as to secure primary union; using fine needles, fine 
silk, collodion dressing, and slight pressure on the parts; using pins if 
much strain is expected on the sutures or if apprehensive of movement 
of the parts. OPERATIONS ON THE FACE. 
215 
One of the serious difficulties of operating on the face and its cavities is the neces- 
sity of often removing the face-piece through which the anaesthetic is being admin- 
istered, so as to uncover the field of the operation and delay the operator. This 
drawback and the consequent possible dangers are overcome if, after the patient 
Fig. 84. 
Souchon’s intranasal inhaler. 
has been fully anaesthetized by the ordinary method, a tube is passed through the 
nose into the lower pharynx, and the anaesthesia is maintained uninterruptedly by 
injecting through the tube the vapor only of the anaesthetic; thus a free field is 
Fig. 85. 
Souchon’s intranasai inhaler. 
secured. This is accomplished by an apparatus invented by the writer: it is so 
constructed that it can be used with chloroform alone or with ether alone, or with 
a mixture of the two: it is also provided with an attachment to connect it with a 
bag of oxygen or nitrous-oxide gas if desired.1 
1 For detailed description see Medical News, Philadelphia, Nov. 23, 1895. 216 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
Congenital Malformations.—Fissures are more frequent on the 
ridge of the nose than anywhere about the face, and yet these are very 
rare. 
Nasal dermoid fistulse are always ascending, and may reach the dura 
mater. 
Congenital absence of the nose has been observed by Maisonneuve : 
it was in a child nine months old. There existed only a flat surface with 
two small holes. Langenbeck recommends in these cases the transplan- 
tation of the periosteum of the frontal bone. Occlusion of the nostrils 
has been noticed. Congenital clefts and fissures of the nostrils are due 
to incomplete closure of the branchial fissures of the cheek or of the 
naso-genial fissures ; they are directed usually toward the external angle 
of the eye. Plastic operations are necessary to remedy the defect. A 
bifid nose due to a fissure between the lower lateral cartilages is recorded 
by Verneuil, Thomas, Borrelli. 
Congenital hypertrophy has been observed. 
Double noses exist; they are more or less well formed. The remedy 
consists in removing one and closing the gap by a plastic operation. 
Sometimes the additional nose is a tumor. 
Congenital deviations are more or less frequent, such as parrot nose, 
saddle nose, pug nose, excessive deviation to the right. 
A case is reported of the successful removal of a morbid mass implanted on an 
abnormal bifurcation of the nasal bone, and in which was recognized the rough 
appearance of a foetus: at the lower part of this foetal mass, between its thighs, 
was noticed a penis, cavernous and erectile. 
Acquired Malformations of the Nose.—Destruction of the nose 
is frequent enough as a result of injuries by ulcerations. A plastic ope- 
ration is necessary to remedy the defect, or the wearing of an artificial 
nose supported by spectacles. 
Closure of the nostrils follows burns, fractures, and small-pox : the 
contracted nostrils should be dilated gradually like other strictures ; the 
dilatation must be kept up so as to prevent recontraction. 
Depression or flattening of the bridge may be due to fractures or to 
syphilis. 
Rhinoscleroma is peculiar to the nostrils and to the skin around them: it 
begins by nodules in the cutis, which coalesce to form a hard growth with a smooth 
glistening surface, which spreads inward from the lip and downward to the pharynx: 
it is a very rare affection. It should be removed as early as possible. 
Elephantiasis affects the nose markedly. Hypertrophy, pure and simple, is 
frequent enough. Hypertrophy of the lobule is not rare in those cases of acne 
rosacea where are found scattered hypertrophic conditions called “ lipoma nasi.” 
Expansion or flattening of the bridge, or frog-face, is observed when tumors, 
originating inside, polypi, hernia cerebri, are growing to the outside. 
Acquired deviations from blows, falls, causing fractures, dislocations 
of the cartilages or of the bones, are rather common. 
Burns are grave because of the deformity that follows. It is import- 
ant to keep the nostrils well dilated with tampons to prevent their clos- 
ing ; it is also important to prevent scratching; grafting must be resorted 
to in time when necessary. 
Freezing of the tip of the nose is frequent in very cold climates. It is 
announced by a white discoloration: Avhen vesicles appear, they denote an 
Surgical Diseases and Injuries of the Nose, Exterior. SURGICAL DISEASES AND INJURIES OF THE NOSE, EXTERIOR. 
217 
unfavorable condition. The nose should be rubbed with snow at once; the reac- 
tion should be slow, lest the mortification be rendered inevitable or worse. The 
nose is sometimes the site of chilblains (erythema pernis). 
Contusions of the nose are common. 
Punctured wounds are rare. Incised wounds need no sutures unless the cartilages 
are involved: it is very important to properly approximate the edges, especially if 
the nostrils are involved, because a very small deviation makes an unsightly and 
ever-noticed scar. Should a piece hang or have been cut off, it should be 
thoroughly cleansed and reapplied, without stitches, by plates and light collodion 
dressing. Contused and lacerated u'otmds require also particular care of the nos- 
trils: if a piece is detached, reapply it or graft in time. 
Dislocations of the nose, cartilages, or bones require treatment sim- 
ilar to fractures. Fractures of the nose are usually due to severe blows 
or falls; fractures of the upper part of the nose require very great force. 
Fig. 86. 
Rhinoscleroma (Dr. Wende’s case). 
The direction is transverse, with backward displacement, if the blow be 
from above; it is lateral if the blow be from the side; in children it 
sometimes happens that the bones are fractured only in the middle, and 
are sunken in. 
The symptoms are those of fractures in general. 
The diagnosis may require an anaesthetic if there he much swelling, as a correct 
diagnosis is important before the bones begin to unite, which may occur before the 
swelling has disappeared. 
The prognosis is serious, because of the probable and frequent deformity: 
very often much prominent deformity follows a fracture which at first was thought 
to be slight. 
The treatment must be directed toward replacing the bones and preventing 
deformity: the fragments should be replaced by using external and internal man- 
ipulations ; internal aseptic tampons should be used with caution on account of the 218 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
possible sepsis. Apply externally strips of plaster and compresses; in cases where 
the fragments fall back they should be raised and supported by passing a needle 
transversely between the fragments and the sound bone. 
A complication that is not uncommon is emphysema if the lachrymal bones 
have been broken or if the mucous membrane has been lacerated: very often 
there is much bleeding, with persistent headache, even with concussion symptoms. 
The latter complication, if grave, may cause death. The dreaded sequel of frac- 
ture of the nose is the deformity: sometimes the nose has to be refractured and 
readjusted; in some cases osteoplastic operations are required. 
Poisoned wounds, stings, bites, present no special remark here, except, of course, 
glanders, which shows externally first by an inflamed and ulcerated condition of 
the nostrils and upper lip. 
Erysipelas often first shows on the tip, coming from the interior of 
the nasal cavities. 
Gangrene of the nose is rare : when it occurs, plug the nostrils to 
prevent strictures; graft in time ; perform plastic operation to remedy 
deformity. 
Reynaud’s disease, described in connection with the face, sometimes 
affects the nose. 
Necrosis of the bone is usually syphilitic, and should be treated as 
in other situations. 
The diseases special to the nose, and not seen anywhere else, are— 
rhinoscleroma (Fig. 86), erythematous lupus, acne rosacea, acne hyper- 
trophy (lipoma nasi). The diseases that are most frequently met with 
on the nose are—naso-genial congenital fissure or fistula.', bifid nose, 
deviations, strumous hypertrophy, frog-face, seborrhma oleosa, frost- 
bite, knock-out blows, glanders, erythema solare, Reynaud’s disease, 
lupus exedens and non-exedens, epithelioma. Scrofuloderma of the 
nose is represented by a peculiar hypertrophic nose and the peculiar 
eczema of the nostrils. Tuberculoderma is represented particularly bv 
lupus. 
Plastic operations for the repair of partial losses or for the construc- 
tion of a whole nose are among the most delicate operations in surgery. 
The operation is called rhinoplasty, and comprises the Italian method 
and Indian method. 
Operations on the Nose. 
The Italian or Tagliacozzian method is named from Tagliacozzi. It consists in 
making a pattern which is applied to the skin of the arm; the skin is then incised 
all around it, but one-third more on every side for shrinkage; a pedicle is carefully 
preserved ; the flap is raised, and is allowed to remain so for about fifteen days, 
when its lower edge is much thicker on the under surface and presents granula- 
tions. Then the edges of the stump of the nose are pared, as also the edges of the 
flap, and the arm is brought in such a position as to allow the ready fitting of the 
flap to the nose, where it is properly stitched. The arm is held in that position by 
a liquid-glass or a plaster bandage or by some special apparatus until union has 
taken place, when the pedicle is severed and the arm released. The upper lip is 
used afterward to make the columna. 
In the Indian method a pattern is also made, and is applied to the skin of the 
forehead, which is incised in exactly the same manner, but the flap is at once 
placed in proper position. Care should be taken not to wound the angular artery. 
The gap created by the taking of the flap is closed by a sliding autoplasty or by 
grafting: it is sometimes advisable to raise the periosteum with the flap, or even 
the outer table of the frontal bone (Konig). For the minute details of these ope- 
rations the student is referred to special works. 219 
MALFORMATIONS OF THE LIPS. 
Surgical Diseases and Injuries of the Lips. 
Congenital Malformations of the Lips.—Absence of the lips, or 
aeheilia, is very rare. Astomia is absence of the buccal orifice, which is 
different from the simple atresia due to excess of adhesions of the lips. 
Atresia of the mouth, when incomplete, is narrowing of the buccal ori- 
Fig. 87. 
Complete bilateral fissures (coloboma) of face (Guersant). 
fice ; when complete, it is also called imperfection: this differs from 
astomia in this, that behind the lips there is a buccal cavity. Incom- 
plete atresia is also called phimosis of the mouth : sometimes the oblite- 
rated mouth is replaced by a congenital genian fissure. Atresia of the 
Fig. 88. 
Fig. 89. 
Incomplete hare-lip (Bruns). 
Complete fissure in double hare-lip (Bruns). 
orifice of the mouth, without loss of substance and without adhesion of 
the jaws, may be called ankylocheilia ; it is usually due to lupus, syphilis, 
variola ; in one case the orifice was completely closed. 
Congenital fissures all start from the lip; they present the follow- 
ing varieties : fissure of the lip alone, or prolonged fissures which extend 220 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
toward the face or the neck; the prolongation is sometimes a mere cica- 
tricial line looked upon as an intra-uterine cure of hare-lip. The hare- 
lip is simple when it involves only the lip; it is complex when it affects 
also the alveolar process or the hard and soft palates. The other varieties 
are the ordinary or vulgar hare-lip—i. e. a fissure under the nostrils; 
the coloboma or bucco-orbital fissure (Fig. 87), external to the wing of 
the nose; the median fissure, the genian commissure, and the median 
fissure of the lower lip. Commissural fissures constitute macrostoma ; 
they are compound or associated fissures. 
Congenital fistules of the lower lip are often represented by two small orifices 
symmetrically situated on each side of the fraenum and opening on the free edge 
of the lip nearer to the mucous surface; sometimes there exists also a hideous 
ectropion of the lower lip, and also a transverse groove. 
Median fissure of the lower lip, varying from an inch in width to a regular 
Fig. 90. 
Fig. 91. 
Double hare-lip with philtrum or snout (Park). 
Complete fissure, with labial defect and pro- 
jecting intermaxillary (Bruns). 
groove, which may be prolonged as a continued line as low as the sternum; the 
lower maxilla may also be involved; also the tongue may be bifid. 
Branchial fistulas of the lips have been observed. Atrophy of one lip, causing 
tightness of the same or of both lips, is not uncommon. Congenital microstoma, or 
small mouth, is mostly due to arrest of development of the maxilla. Macrostoma, 
large mouth, or fissure of the cheek, is due to the lack of closure of the branchial 
fissures; the commissure is extended into the cheeks horizontally or upward or 
downward, on one side or on both sides. Median fissure of the upper lip is very 
rare on account of the peculiar development of the middle portion of the upper 
lip. 
Hypertrophy of the lips is not infrequent. Macrocheilia is thick everted lip; it 
is a condition of lymphoedema. In the general hypertrophic form all the struc- 
tures are involved; the upper lip especially is affected ; it may involve only the 
mucous membrane and form a sort of chemosis of the lip, or it may involve also 
the glandular layer and increase the appearance, or the whole lip may be involved ; 
the mucous surface of the lip is covered with a rough, wrinkled mucous mem- MALFORMATIONS OF THE LIPS. 
221 
brane, presenting a separate pouch on each side of the median line. ( Vide Chapter 
XXX. Vol. I.) Mucous ectropion, or hypertrophy of the mucous membrane or 
extrophy of the lips, is usually congenital. Congenital hypertrophy is not uncom- 
mon in strumous subjects, especially of the upper lip. Macrocheilia is a special 
form of congenital hypertrophy of the lips ; it is different from the big lip of the 
scrofulous, of cretins, of paralytics, of 
negroes: the cause is unknown; it is 
congenital; it is most common to the 
upper lip, whereas angeio-elephantiasis 
selects the lower lip. The alveolar bor- 
der is also affected; the lip may be 
increased as much as 14 centimeters in 
length, 8 in height, and 3 in thickness. 
It is composed of fibrous tissue, hard 
enough to creak under the knife, with 
star-like cavities lined with epithelium 
and containing serum and lymphoid 
cells. Hirsuties of lips, or overgrowth 
of hair, is sometimes observed in 
females. The following depilatory is 
useful: 3 parts of prepared chalk to 1 
part of sulphide of calcium; make a 
paste and apply with a brush ; let dry 
and then brush off the hairs; they 
grow again and the process has to be 
renewed. The best mode of treatment 
is electrolysis by means of a fine needle, which is glided along the hair-root to the 
hair-papilla, which is then destroyed by the current. Congenital deviations of the 
lips in the form of eversion or ectropion, or inversion or entropion, are quite rare 
without hypertrophy. All these cases of malformation are remedied by incisions, 
excisions, with or without plastic operations more or less elaborate. 
Fig. 92. 
Illustrating the osseous (palatal) defect in com- 
plete fissures (Bruns). 
Fig. 93. 
Projecting intermaxillary bone (Bruns). 
Acquired Malformations of the Lips.—Acquired microstoma, or 
union of the lips and closure more or less complete of the mouth, has 
been observed after burns, injuries, idcers and removal of tumors. Atresia 
of orifice of mouth, with loss of substance and adhesions to the jaw, is 
called syncheilia; it is the rule after cancrum oris. As a result of all 
these deformities there is constant dribbling of the saliva and dropping 
of the food during mastication. 222 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
Acquired macrostoma, or large mouth, is also the result of similar causes. Cica- 
trices around the mouth are observed in children affected with congenital syphilis, 
and they may also present a scarred or a fissured aspect at the angle of the lips 
and cheeks. Acquired deviations or distortions of the lips may be directed 
upward, downward, or outward ; may affect one side or both ; most commonly it is 
ectropion that is observed, due to cicatrices from burns, injuries, gangrene, ulcers, 
operations; sometimes the lower lip is thoroughly everted and is attached to the 
skin of the neck. All these interfere with speech and the proper retention of the 
saliva. Acquired ectropion, or eversion of the lips, may be paralytic, mucous, and 
cicatricial. Cicatricial ectropion of the lips is due to the retraction of a cicatrix. 
Scars of the lips do not grow small with age, but grow with the body; the con- 
spicuousness of the scars make them doubly objectionable. 
Chronic swelling of the lips, or hypertrophy, is usually due to chronic lymphan- 
gitis ; the cervical adenitis increases the lymphangeiectasic condition by becoming 
an obstruction to the course of the lymph. Chronic swelling of the lower lip is 
more rare in scrofulous subjects, but in idiots, cretins, and paralytics the lower lip 
is always pendulous and moistened by the constant running of the saliva. It 
constantly exposes to air and cold its ulcerated mucous surface, all of which causes 
a chronic thickening. In cases of old rebellious indurated lips the excision of a 
V-piece is necessary. The diseases of the bones of the jaw also affect the shape 
of the mouth, and must be studied with them. 
Injuries of the Lips.—Burns of lips by acids (nitric, hydrochloric, 
sulphuric), when on the cutaneous surface, are usually the result of a 
criminal attempt; when on the mucous border, they are due usually to 
suicidal efforts. 
Burns of all kinds are followed by cicatrices, which are very disfiguring; prac- 
tise early and thorough grafting. ( Vide Fig. 24, Vol. I.) Frost-bite does not affect 
the lips as often as the nose, in spite of their exposed condition. Freezing or 
effect of cold on the lips is usually a crack on the middle line of the lower lip, 
especially in young or lymphatic subjects; it is sometimes the cause of strumous 
lesions of the lymph-nodes. Contusions of the lips are usually accompanied by a 
great deal of swelling; the ecchymosis is oftener submucous, which is due to the 
greater softness of the tissues there and to the action of the teeth. 
Punctured wounds are rare. Incised wounds bleed very freely : when 
perpendicular to the fibres of the orbicularis they present great separation 
of the edges, and are followed by a cicatricial notch; when the artery 
is injured the hemorrhage is profuse, especially if the wound be near the 
commissure; torsion and suturing usually stop it. Wounds on the 
mucous surface bleed more freely, because the arteries are nearer the 
mucous membrane. It is most important to approximate the vermilion 
border properly; be careful to prevent notching: when the whole lip is 
divided through it is safer to use a pin suture. Contused and lacerated 
wounds are frequent ; sometimes the injury inside inflicted by the teeth 
is great, without any outward sign. They often resemble an incised 
wound because the teeth cut through from the deeper surface. It is 
best to convert lacerated wounds into incised ones by paring the edges, 
thus preventing ugly cicatrices and keloids ; sloughing wounds should 
be pared down and sutured as soon as the granulations are healthy. 
Wounds of the lips with loss of substance, such as bites by a man in a 
scuffle, by dogs, by horses, are not rare, on account of the shape and 
position of the parts. Poisoned wounds, stings of bees, of spiders, of 
insects, are accompanied by great pain, swelling, and disfigurement. 
Inflammations.—Furuncles and carbuncles are comparatively fre- 
quent, especially on the upper lip; the swelling usually affects the 
mucous side, and it is followed by protrusion of the lip, ulceration, and SURGICAL DISEASES AND INJURIES OF THE LIPS. 
223 
ectropion. They are especially dangerous here on account of the com- 
plication of phlebitis of the facial vein, which may extend to the sinuses 
of the brain. Owing to the peculiar anatomy of the parts, carbuncles 
present a diffuse swelling, are hard, of a brawny dusky color; they 
spread rapidly ; the lips are their site of predilection; they are often 
followed by simple strumous adenitis (not tubercular). 
Gangrene of the Lips.—Canerum oris is phagedenic gangrene of the 
corner of the lips and of the corresponding portion of the cheeks; it 
involves the whole thickness of the lips ; it is observed in ill-nourished 
and weak, ill-fed children ; it is often followed by great deformity ; the 
jaws may be drawn down by firm cicatrices; in some cases there is also 
necrosis of the bones. ( Vide Arol. I. Chapter Y., Fig. 29.) 
Ulcers of the Lips.— Tuberculosis of the free border of the lips is 
found in patients with lung tuberculosis; sometimes it is due to direct 
inoculation, due itself to a wound from a projecting tooth, contact of 
a pipe-stem, or puncture with a fork; it is characterized by an ulcer 
with a peculiar bottom, granular, edges not prominent, irregular, per- 
pendicular, somewhat serpiginous ; around it the mucous membrane is 
purple, strewn with yellow dots; the surrounding tissues are most usu- 
ally indurated ; the nodes may be affected. Tubercular lesions are rare, 
especially on the lower lip; it is usually due to the extension of the 
lupus of the face. Lupus of the upper lip has a tendency to invade and 
destroy the nose ; it is often remarkable for the concomitant swelling. 
Syphilitic ulcers are comparatively common under the form of chancres, 
which are more common on the lower lip. Indurated chancre of the lip 
is the most frequent of the extragenital chancres, especially in women 
and children. It is due to direct contact with mucous patches of the 
lips by a kiss or by a bite in a scuffle, or by indirect contact with the 
fingers, pipes, spoons, glasses, etc. It often occupies the mucous surface. 
The forms peculiar to the lips are—the fissuric chancre; the commissural 
or the median formed by two tubercles growing away from each other: 
erythematous chancre and dwarf chancres are mere erosions, and are not 
recognized until the secondary symptoms show themselves. One lip may 
become inoculated with a chancre from the other lip; gumma of the lips 
may become indurated and resemble a chancre, but will present a depressed 
centre and no nodes. Labial chancres require a longer time to cicatrize 
than the genital chancre: it is said that syphilis thus contracted is more 
severe than the genital. Mucous patches are also common. The infection 
is due to auto-inoculation through bad habits, lack of cleanliness. When 
the ulcers occupy the corner of the mouth, look for syphilis. Remains 
of hereditary syphilis, early or tardy, have been observed especially on 
the upper lip; the lesions are those of sclerosis, with hypertrophy and 
ulcerative gummata. The disease resembles lupus very much. Can- 
cerous ulcers take the form of epithelioma, which is the cancer of the lip, 
especially of the lower lip; it will be described separately farther on. 
Tumors of the Lips.—Liquid hsematoma is rare, serous cysts are 
rare, but mucous cysts due to the obliteration of a gland are not uncom- 
mon : they most commonly occupy the inner surface, and contain a 
thick, sticky mucus. Angeiomata, or erectile formations, are most 
commonly congenital; they may affect the skin, the subcutaneous tis- 
sues, or the whole lip; they constitute a serious affection when they 224 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
are large, owing to the great destruction of tissue required in their 
removal. Angeiomata of the lips are frequent ; the lips are a point 
of election. When cured the fibrous induration may form an unsightly 
tumor. 
Chronic abscesses of the lips are rare. Hsematomata with clotted blood are 
seldom seen on the lips, oh account of the matted condition of their structure. 
Sebaceous cysts are common, and present difficulty in their dissection. Dermoid 
cysts are seen occasionally. Lipoma is very rare, but is sometimes observed; it is 
lobulated, soft, fissured. Lipomata are not rare on the lower lip; the lining mem- 
brane over them is grayish or yellowish; some of them are very vascular, like 
Fig. 94. 
Fungating epithelioma of lip (Smith). 
erectile tumors; adenoma has been observed. Syphilitic gummata are rare. 
Tertiary syphilis of the lips presents sclero-gummous lesions; circumscribed 
gumma of the lips is rare; it is seen more frequently on the upper lip; diffuse 
syphiloma of the lips is more common on the lower lip. In the rapid form the 
lip is fissured in two or three days, and swelling is present; in the slow form 
the progress is longer; it has a chronic course. Papilloma, mucous or corneous, 
has been described; also horny papilloma. Myxoma has been observed; also 
uncommon. Keloids are rather common on the lips. Neuroma has not been 
reported. Fibromata present three or four cases on record. Chondroma is rare. 
Osteoma is unobserved. Sarcoma is very rare. Salivary cysts of the glandules of OPERATIONS ON THE LIPS. 
225 
the lips are comparable to the grenouillette; they are more common on the lower 
lip. Some few cases of cysticercus are reported. Filaria of Medina, or filaria 
labialis or filaria hominis oris (Leidy), have been observed under the mucous 
membrane. 
Epithelioma of the lower lip is a frequent disease in men, but rare 
in women. It is said to be often due to the irritation produced by a 
carious tooth, and most frequently by the contact of a short pipe-stem. 
Sometimes a chronic fissure resembling an ulcer is the starting-point. 
W e must remember that an ordinary ulcer touched by a solid stick of 
lunar caustic will usually heal rapidly, whereas it has no effect on epi- 
thelioma, but sometimes stimulates its growth (Fig. 176, Vol. I.). 
Epithelioma presents the following clinical forms and varieties, according to 
the size and character of the ulcer, to the condition of the adjacent lymph- 
nodes and the skin : It may be flat or superficial, presenting scales or an inflamed 
sebaceous outlet: this is the less grave form. It may be indurated or circum- 
scribed, with a raised edge, beyond which the tissues look and feel sound; 
because of this limitation this variety is the less objectionable. There is also a 
papillary form, with well-defined, non-indurated edges—and a diffused form, 
which resembles the condition of chronic inflammation, sometimes beginning by 
separate spots which coalesce, with elevation of the diseased part: this is the 
worst form, because it leaves the surgeon always in doubt as to whether he has 
thoroughly removed all the diseased tissues beyond the microscopically infiltrated 
or infected parts. It usually runs a more rapid course than the others. Epithe- 
lioma with nodes affected on both sides is of no very uncommon occurrence; with 
digastric nodes affected it is a very rare form; even when the whole lip is affected 
it is rare to find these nodes, which receive only the lymphatics from the middle 
of the lower lip. 
Operations on the Lips. 
Hare-lip should be operated early, but the health and strength of 
the child are more important than the age; the operation may be per- 
formed from the sixth week to the third month, but we must bear in 
mind that very young children do not stand bleeding well. Early 
operations are indicated especially in double hare-lip when the child 
Fig. 95. 
Fig. 96. 
Malgaigne’s operation: the incision. 
Malgaigne’s operation : the sutures in position ; 
the lower sutures tied. 
cannot suck if strong enough: no operation should be performed if 
there exists any sickness from dentition or other cause. The operation 
consists in paring the edges freely and bringing them together, and 
holding them with deeply buried pins and sutures. The pins should be 226 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
removed after forty-eight hours. In paring great care should be taken 
that no notch may remain after the operation. The accompanying 
plates explain the procedure most satisfactorily. For seventy-two hours 
after the operation the child should be fed with the spoon and also by 
enemata; opiates should be given for the pain. 
Double hare-lip may be operated on in one sitting if not too extensive. 
In hare-lip with projection of the intermaxillary bone this bone should 
be pushed in, if possible; if not, it should be excised. Hare-lip with 
Fig. 97. 
Fig. 98. 
cleft of the hard palate should be operated early, as it will exert an 
approximating effect on the bones and will tend to diminish the fissure. 
In hare-lip with congenital fissure of the cheek the fissure should be 
closed at the same time. Hare-lip with deficiency or partial atrophy 
of the sides of the cheek calls for plastic and osteoplastic operations if 
the condition of the child allows; sometimes there is free bleeding from 
the artery of the septum ; the orifice of the wound should be plugged. 
Hare-lip with general malnutrition is always grave, because the mal- 
X(Slaton’s operation: the incision. 
Nelaton’s operation: the sutures. 
Fig. 99. 
Fig. 100. 
The operation for double hare-lip. 
Operation for double hare-lip: the sutures in 
position. 
nutrition is often due to the defective condition of the lip, which inter- 
feres with nursing. Nutritive enemata should be used freely, and the 
operation performed as soon as the child’s condition permits. 
The principal operation upon the lower lip is the removal of an 
epithelioma. It is most important to operate early, before the nodes 
become involved; small or even large epitheliomata without lymphatic 
involvement may be cocainized and curetted, or excised. 
The general principles of thorough asepsis must be observed here as 
everywhere else. An assistant compresses the inferior labial arteries; SURGICAL DISEASES AND INJURIES OF THE CHIN. 
227 
with long curved scissors or with a knife the diseased parts are cut 
away, and spurting arteries are secured; a strong double silk suture is 
then passed through the upper part of each flap, and an attempt is made 
to approximate the parts, which manoeuvre shows the extent of the loss 
of substance. If this be such as to require it, each flap is to be detached 
from the bone and partially from the cervical fascia in order to bring 
the edges together without strain. This approximation is best effected 
with pins and silk, because they resist the contraction of the muscles 
better than other kinds of sutures, which cut more easily under the 
involuntary movement of the patient. The mouth is usually very much 
puckered as a consequence of this suturing, but the tissues yield 
remarkably with time. 
In very extensive disease the flaps must be detached from the bone and, if 
necessary, dissected as far back as the angle of the jaw and as low down as the 
thyroid cartilage, in order to be able to bring the sides together: the flaps must 
consist of the skin and platysma, and the line of dissection should be the layer of 
connective tissue between the platysma and the cervical fascia. Sometimes regu- 
lar plastic operations must be performed. In epithelioma with lymphatics adhe- 
rent to the bones, these must be well scraped and even cut away. AYhere union 
has once failed one should wait until the tissues are thoroughly removed, because 
primary union may fail again. Epithelioma recurring on the lips or in the nodes 
must be operated on at once; it is the last and only chance. 
Cheiloplastic operations—i. e. plastic operations on the lips—are per- 
formed for restoration of the upper or lower lip or for deviations of the 
angles. They consist in sliding flaps with a pedicle, or in transplanting 
Fig. 101. 
Fig. 102. 
Estlander’s cheiloplastic operation. 
flaps from the neck and face : these flaps must be muco-cutaneous—that 
is, formed of skin on one side and mucous membrane on the other. 
Skin-grafting is often of useful assistance in filling gaps. 
Congenital Malformations.—Absence of chin is a possible malfor- 
mation due to an arrest in the development of the parts, especially of 
the bones. 
Congenital atrophy of the chin, as well as double chin, is observed as 
the result of an incomplete fusion of the two halves of the face ; an 
accumulation of fat causing thick folds under the chin is also called 
double chin. Congenital deviations forward, or gcdoche chin, or laterally, 
are not uncommon. 
Hypognathy is a malformation characterized by the implantation of a super- 
numerary inferior maxilla by its own symphysis on the symphysis of the subject: 
Surgical, Diseases and Injuries of the Chin. 228 
SURGICAL DISEASES AND INJURIES OF T1IE FACE 
the implanted maxilla is a real one, having the same shape, more or less, and con- 
taining dental sacs. Sometimes the implantation is bony (myognathes), or is only 
soft and loose, or it may be pediculated (dermiognathes). It is a tumor of unequal 
density, here bony and hard, there soft; cysts may develop in its interior and 
attain great development. It may grow toward the chest, the mouth, or the 
neck. 
Injuries of the Lips.—Burns of chin present nothing peculiar; nor 
does frost-bite, except in its greater frequency because of the exposed 
situation. Suicidal attempts at shooting beneath the chin seldom kill, 
because the patient usually throws his head backward while the pistol is 
directed upward : they usually result in the destruction of the lower lip 
and under portion of the inferior maxilla. 
Indurated chancre of chin is mostly due to a barber’s wound with a contami- 
nated razor: it is often scabby in that region. Fistulse and tumors of all kinds 
are comparatively rare and present nothing special. 
Surgical Diseases and Injuries of the Cheeks. 
Congenital malformations and branchial fissures, resulting from 
the lack of union of the branchial arches, are not uncommon. They 
may be horizontal or angular ; they may be vertical when the failure of 
union is located between the extremities of the branchial lamina and 
the frontal bud from which the nose and the middle of the upper lip 
are developed ; they may be unilateral or bilateral. 
Congenitalfistulce have been observed on the cheek exceptionally. Congenital 
salivary fistula, due to a similar mode of production, are on record. There is no 
recorded case of absolute absence of the cheek. Congenital atrophy of the cheek 
is marked by a considerable sinking of the region; it may be due to a want of 
development of the bones, the teeth, or the ball of fat that exists between the 
masseter and the buccinator. Congenital deviations are sometimes observed at 
birth as a result of the paralysis of the facial nerve due to the pressure of the 
forceps or to purely structural changes. Swellings of the cheeks are most com- 
monly caused by a bad tooth; the next most common cause is an abscess of the 
antrum. 
Injuries of the Cheeks.—Contusions are not rare: when they 
involve the malar and frontal bones they are said to be followed by 
amaurosis, due not to reflex action, but to injuries (detachments) of the 
lens, iris, retina, or choroid, or to extravasation of blood in the cham- 
bers of the eye. Burns and frost-bite, extending to Stenson’s duct and to 
the facial nerve, are followed by salivary flstulae and paralysis of the face. 
Punctured wounds present nothing peculiar unless they pierce the 
facial artery or vein or Stenson’s duct. Large perforating wounds may 
leave a permanent fistulous opening through the cheeks. 
Wounds of Stenson’s duct must be attended with solicitude to prevent a fistula ; 
they are more rare than those of the gland, being protected by the malar bone and 
zygoma. The division is usually complete; they are followed by the escape of 
saliva; if union fails, there occurs a fistula or a salivary tumor between the two 
divided ends, which fills at meals and empties after by pressure; obliteration of 
the canal and atrophy of the gland may follow. In recent wounds stitch the duct 
ends together; in old wounds introduce catgut in distal end; then press on the 
parotid to discover the proximal end, and stitch it to the catgut of the peripheral 
end. The wound should be enlarged if necessary, and the proximal end curved 
into the interior of the mouth and retained there by sutures. ( Vide below.) 
Wounds of the branches of the facial nerve should also be stitched 
if possible: although the branch may be small, yet if paralysis should SURGICAL DISEASES AND INJURIES OF THE CHEEKS. 
229 
follow its injury, the result may be most serious, especially if it be the 
branch distributed to the orbicularis of the eyelids. Fractures of the 
malar or of the zygmotic arch are rare, because very great force is 
required to produce them : most commonly the arch is broken and 
depressed. It should be raised by means of a narrow lever. If the 
fragment be loose and falls back out of place, it should be raised with 
Fig. 103. 
Salivary fistula: treatment by single puncture (Hartmann). 
two or three silver sutures passed under it and tied over a sterilized 
small aseptic splint placed over the extremities of the facial bones. 
Inflammation of Stenson’s duct is called sialo-ductilitis : it is more rare 
than that of Wharton’s duct. Bristles, fish-bones, straws, tooth-brush 
hair are the usual causes; it is sometimes due to propagation through 
Fig. 104. 
Salivary fistula: Richelot’s method by double puncture and insertion of drainage-tube 
(Hartmann). 
the mouth ; there is swelling of the gland, abscesses, fistulse. Fistulse 
may be due to carious teeth or bone. 
Fistula of Stenson’s duct is usually situated on the buccinator: the 
orifice is narrow and in the centre of a granulation or in the midst of 
cicatricial tissue; a viscous fluid is discharged, increasing during masti- 
cation. Lymphatic fistulte of the region are rare; their outpour does 230 
SURGICAL DISEASES AND INJURIES OF THE FACE. 
not increase during meals; the liquid coagulates ; sulphocyanide of 
potassium is absent from it. Fistulae of the parotid gland are recog- 
nized by exploring with a probe from the mouth. 
The treatment consists in the cauterization of the orifice, its compression 
with collodion to produce occlusion, or in operative closure. These measures are 
good if the peripheral end is pervious; if not, we must re-establish the course of 
the saliva toward the mouth by re-establishing the normal canal, which is difficult. 
Fig. 105. 
Salivary fistula placed anteriorly to border of masseter; double puncture of mucous membrane 
and enclosure of portion in a wire loop; fistula thereby made internal (Hartmann). 
One operates from within the mouth by passing a threaded needle around the duct 
back of the fistula, penetrating and coming out as nearly the same point as feasible, 
having the duct in the loop, but leaving out the skin, then tightening, or by single 
puncture and drainage when the fistula corresponds to the anterior border or 
occupies the region of the masseter. When the course of the saliva is re-estab- 
lished, then the fistula is pared and closed. Other means are—causing atrophy of 
the parotid by compression or by ligation of Stenson’s duct behind the fistulous ori- 
fice, or by injection of oil or iodine into the duct: this is very successful on the 
horse; it never cures in man. (For other methods see Figs. 103, 104, 105.) 
Tumors of the Cheeks.—Cysts of Stenson’s duct and dermoid cysts 
have been observed near the parotid region, in the depth of the cheeks, 
or in the course of the infundibuliform fissure. 
Angeiomata of the fatty ball of Bichat are usually well circumscribed, 
stationary, and may obliterate Stenson’s duct and be accompanied by 
parotidean lithiasis; the superficial veins are dilated. Lipoma of the 
fatty mass of Bichat usually becomes superficial in the cheek in front 
of the masseter or malar bone, or submucous when the yellow colora- 
tion is sometimes seen ; sometimes it ascends under the temporal fascia. 
Sarcomata of the fatty ball of Bichat have been observed ; they grow back- 
ward. Angeio-sarcomatous cysts of the cheek have been observed over the 
masseter. Salivary colic is sometimes observed, due to the passage of a calculus 
through Stenson’s duct. 
Diseases of an Accessory Parotid.—Tumors of the cheek some- 
times originate from an accessory parotid gland or from Stenson’s duct. 
Cysts with a glandular epithelial lining are forms of grenouillette of 
the accessory parotid. CHAPTER Y. (Continued). 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
Edmond Souchon, M. D. 
Congenital Fistula of the Neck. 
These are due to arrest of development or lack of fusion of the 
branchial laminae or folds and clefts of the pharyngeal fissure; they are 
sometimes hereditary, but are sometimes discovered only a long time 
after birth. They may be due there to a cyst which has ruptured 
externally. They are usually very small, seldom admitting more than 
a case probe, exceptionally the end of the little finger. The external 
orifice is situated most commonly on the right side of the neck in front, 
and behind the sterno-mastoid, and between the thyroid cartilage and 
the sterno-clavicular articulation; sometimes, but rarely, at the angle 
of the jaw; it is sometimes on a projection, at other times in a fold of 
the skin; it occasionally presents cartilaginous or osseous particles; it 
may be found blocked by the dried secretions. These fistulse resemble 
congenital tracheal fistulse, but open less commonly on the middle line; 
they are rarely found on one side, and still more rarely on both sides. 
The internal orifice may open into the pharynx or larynx or trachea: it is 
observed almost always near the tonsil and base of the tongue, and is very small; 
it may become the starting-point of serious inflammation and abscess. When 
complete an injection of milk penetrates the pharynx or the larynx. These fistulae 
may be externally or internally blind: the externally blind are by far the most 
frequent. The course of the fistula is marked by a cord-like-tract which corre- 
sponds to the tract of the fistula; its direction is straight or tortuous, oftenest in 
the direction of the great horn of the hyoid bone; it is constituted by an external 
thick, fibrous coat which forms the cord and is lined by a sort of mucous mem- 
brane which secretes a thin, viscid fluid containing epithelial cells or puruloid. 
Internal blind fistulse are very rare, but positively exist. They present the variety 
called diverticula “ by pulsion ” of the pharynx and oesophagus, due to the dilata- 
tion and development of an originally small pouch under the influence of the 
accumulation of the food; they sometimes form very large tumors. The diag- 
nosis of congenital fistulae rests upon the secretion of the fluid, the presence of 
the cord, the penetration of the probe, and the injection of colored fluid. Con- 
genital fistulae are almost always stationary; the lesion is more of a deformity 
than a disease. 
Treatment is usually unnecessary, and fortunately so, because it usually fails 
when limited to stimulating injections, dilatation, or curetting, and excision is a 
laborious operation, not without danger, and scarcely justified by the inconvenience 
experienced. Both orifices may close and leave an intermediate tract. 
Congenital atrophy of the whole or of more or less extensive parts 
of the neck is very rare without participation of the rest of the body. 
Congenital atrophy of the sterno-mastoid has been observed. 
Contusions are not frequent: they are usually produced by falls, blows, 
hanging, garotting, throttling, passage of a wheel over the neck, or by 
the pressure of the dislocated clavicle. A blow on the side of the neck 
231 232 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
is a great aim with pugilists, because it is almost a sure knock-down or 
knock-out; it is often grave, because of the importance of the organs 
of the neck, and may be accompanied by fracture of the hyoid bone, 
larynx, and trachea, injuries to muscles, vessels, nerves, pharynx, oesoph- 
agus, vertebral lesions, concussions and contusions of the spinal cord. 
A haematoma may form and become large, and cause grave pressure 
symptoms on all the structures. Death may occur after a few days from 
oedema of the lungs, also from embolism from one of the large vessels 
of the neck. 
Wounds of the neck are comparatively rare in civil practice; 
sometimes they are accidental, and due to a fall on a fragment of 
glass, a stem of iron or of wood; they are most commonly due to at- 
tempts at murder or suicide; the latter are the most common and most 
instructive. 
Superficial or extrafacial wounds of the neck—i. e. wounds not ex- 
tending beyond the superficial cervical fascia—present nothing peculiar. 
However, a large incised wound of the external or anterior jugular, 
especially if it happen to be unusually large, may give entrance to 
air. In tracheotomy the anterior jugular is often wounded ; also the 
inferior thyroid veins. If the parallelism of the lips of the wound has 
been disturbed, there may be much infiltration of blood: this requires 
enlargement of the incision and ligation in preference to pressure ; cellu- 
litis spreads rapidly. Gunshot wounds are rare, yet there are instances 
where a bullet has travelled under the skin and above the fascia without 
penetration of the fascia. Contused and lacerated wounds, if extensive, 
may be followed by cicatrices and their consequences. Gunshot wounds 
causing much destruction of skin present the same marks as the lace- 
rated wounds. Deep or subfascial wounds are almost all very serious, 
because of the almost constant injury of some of the large vessels and 
nerves or of the special organs of the neck—larynx, trachea, pharynx, 
thyroid body—giving passage to air, food, blood; each of them calls for 
appropriate treatment. 
The symptoms of entrance of air into the veins are a wind-suck- 
ing or gurgling sound, immediate pallor of the face, dilatation of the 
pupil, irregular or tumultuous action of the heart, embarrassed breath- 
ing, and sometimes death. The wound should be plugged at once with 
the finger, and all the usual means of resuscitation vigorously and 
persistently applied. The amount of air introduced is a grave factor. 
If the wound be small, the operation may be continued by keeping it 
constantly filled with warm sterilized water. 
Dislocations, also sprains, are the result of injuries in which the head 
is much stretched, most commonly and especially when violently strik- 
ing an obstacle, vertex first: they give rise to great pain, particularly 
when the head is thrown backward. 
The treatment consists in thorough rest of the part by lying on 
a bed or by applying a liquid-glass bandage. 
Poisoned wounds—i. e. bites, stings—are more frequent on the neck 
on account of its exposed condition; also more grave, because no cloth- 
ing has protected the parts; also, because they are usually followed by 
great swelling, which, reaching the aryteno-epiglottic folds, causes 
obstruction of the larynx. CELLULITIS AND ABSCESS OF THE NECK. 
233 
In all injuries of the neck causing obstruction to the free circulation 
of the air, from whatever cause, there are great dyspnoea, cyanosis, 
anxiety ; the pulse is full, rapid; there is also aphonia, dysphagia, pain. 
Tracheotomy should be performed : it is often advisable not to wait for 
very urgent symptoms, because death may come on rapidly or suddenly 
before the patient can be reached to have the operation performed. 
Cellulitis, deep or subaponeurotic, is a very grave atfection, because 
of the compression due to the swelling, and because these symptoms 
are increased by the unyielding nature of the fascia. It may be primary, 
the result of cold, or secondary, due to some injury or some lesion of the 
teeth, especially of the wisdom teeth, bones, lymphatics, thyroid body, 
scalp, ear, face, mouth, or to low fevers. It may come from neighbor- 
ing organs : tonsillar abscess sometimes opens under the inferior maxilla, 
and deep axillary abscess in the supraclavicular region, as may also 
an anterior mediastinal abscess. 
Abscesses following injury or scarlet fever sometimes form a hard 
mass, slow in suppurating, causing great damage ; sometimes they bleed 
alarmingly when opened or even after they have been opened several 
days, on account of sloughing of the vessels ; they may be accompanied 
by thrombi in the large veins or sepsis. When the cellulitis suppurates, 
the abscess may be circumscribed or diffuse; the pus may fuse in the 
chest, in front of the thyroid and sternum (previsceral route), behind 
the pharynx and oesophagus (retrovisceral route), or along the carotid and 
jugular vessels in their sheath or in the sheath of the nerves of the 
brachial plexus behind the sterno-mastoid, reaching the supraclavicular 
region and the axilla; it may open into the pharynx, oesophagus, larynx 
or trachea, pleura, mediastinum. Retropharyngeal abscesses may be 
limited: then they project on the sides of the neck in the maxillo- 
pharyngeal space; when they are median they can be reached through 
the mouth. In some subacute cases, in the upper cervical region and at 
the root of the neck, abscesses have a tendency to become encysted, and 
finally open on the skin; they may be chronic. When an abscess is 
near or over the carotid, it pulsates, but there is no expansion. 
The diagnosis of deep abscesses, especially of the acute abscesses, 
should be made at once by using the exploring needle and syringe—not 
a hypodermic needle, which may not give passage to thick pus, but a 
needle at least twice as large as an ordinary hypodermic needle. Explo- 
ration should be repeated every second day if necessary. 
The treatment is of course evacuation and drainage, but in these 
dangerous regions fear of wounding important structures often holds 
the surgeon’s hand when the abscess is one or two inches deep, until it 
becomes more superficial. 
By incising in the middle line and going around the trachea the knife can 
penetrate deeply with safety; also by incising behind the posterior border of the 
sterno-mastoid, and along the base of the jaw. It is recommended by some to 
cut down and ligate the vessels as they are divided, but when these are imbedded 
in indurated tissue it is almost impossible. Others leave the needle in place and 
cut down along it, but the divided vessels present the same dangers and difficulties. 
Hilton’s method is to use the knife only to start, and as soon as deep parts are 
reached to tear with the director and use dressing-forceps to dilate the small 
entrance gained into the abscess: it presents the same objections. The writer’s 
method he calls guided dilatation. It consists in the following steps: Use a 
proper needle, as above described, to locate the pus at the depth of one, two, or 234 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
three inches; unscrew the syringe and leave the needle in place; introduce through 
the needle a steel wire seven or eight inches long, until it reaches the bottom of 
the abscess; remove the needle, leaving the wire in place; make a small incision 
through the skin to overcome the only serious resistance to the introduction of the 
dilators; take a trocar (with cannula) of one-eighth of an inch in diameter, per- 
forated from point to handle, and run it over the wire into the cavity of the abscess. 
It penetrates by dilating the tissues by the three blunt edges of its prismatic tri- 
angular point. Then remove this trocar, leaving the wire still in place; take a 
trocar and cannula of three-sixteenths of an inch and introduce it likewise along 
the wire; withdraw the second trocar, and insert in a like manner one of a quarter 
of an inch; then one of five-eighths; finally withdraw the trocar and the wire 
and leave the cannula in place; through the cannula introduce a drainage-tube of 
a quarter of an inch in diameter; remove the cannula, leaving the drainage-tube 
in place. A suitable probe can be introduced through the drainage-tube, and a 
counter-opening made at the proper place. After forty-eight hours the opening 
can be safely dilated to a half inch or more if it is found that the quarter-inch 
drainage-tube is not sufficient. 
By this method the tissues are not cut, but simply uniformly pushed 
aside; there is no cutting at any time, since the edges of the triangular 
point are blunt: a round or conical point sometimes packs the tissues and 
does not penetrate. If a vessel or a nerve is encountered, it is shoved 
Fig. 106. 
Guided dilatation in evacuating abscesses. 
gently aside out of the way : that is one reason why the dilatation should 
be gradual, and why it is not advisable to pass from a one-eighth to a five- 
eighths trocar. There is no difficulty experienced, as far as the introduc- 
tion is concerned, in passing from the smallest trocar to the largest. ( Vide 
Fig. 106.) 
Fistulse of the neck are rare. The tracheal are the most frequent, 
and are oftenest due to incomplete transverse wounds and to the retrac- 
tion and stricture of the lower end: sometimes they result from the 
removal of parts of the tracheal cartilaginous rings in thyroidectomy; TUMORS OF THE NECK. 
235 
sometimes to tracheotomy. They may be congenital, but it is rare. 
Alimentary fistulse communicate with the oesophagus or the pharynx, 
and are called oesophageal or pharyngeal: they are usually the result of 
accident or surgical wounds or follow the opening of extensive abscesses. 
In old fistulse the orifice is circumscribed by a cicatricial ring inti- 
mately adherent to the edges of the loss of substance of the trachea; 
they demand an autoplastic operation. Plastic operations are necessary 
to cure many of those fistulse which remain after the removal of the 
original cause, and after the dilatation and curetting of the tract. 
Tumors of the Neck. 
Aeroceles (laryngoceles, tracheoceles) are tumors formed by air filling 
an adventitious pouch : this excludes pneumatocele. The predisposing 
causes are weakening of the tract and emphysema. The occasional 
causes are strains (cough, labor). Some are congenital dilatations of the 
laryngeal ventricles, abnormal prolongations; some are traumatic and 
due to wounds of the trachea, rupture of the intercartilaginous spaces; 
others are pathological, due to dilatations of the glands of the mucous 
Fig. 107. 
Bilobed multilocular cyst of neck (Lannelongue). 
membrane, to ulcerations, syphilitic or due to former disease of the 
cartilages, or to abscesses. The course varies; they are usually per- 
sistent. The palliative treatment consists in compression. In some cases 
extirpation is possible. 
Pneumatocele is due to hernia or great protrusion of the lung into 236 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
the supraclavicular region : it is recognized by percussion and by its disap- 
pearance upon pressure and its quick reproduction by forced expiration. 
Pneumatocele follows the respiratory movements. 
Cysts of the neck are of several kinds, and are known under the 
following names: mucoid cysts (Lannelongue), branchial cysts, deep 
dermoids, deep atheromatous tumors, congenital hydroceles of the neck, 
hygromata, atheromatous cysts of the lymph-nodes. They are almost all 
rare and congenital; but they are not all branchial. They are situated 
along the course of persistent obsolete tracts lined with epithelium, in 
Fig. 108. 
Congenital multilocular serous cysts (hydrocele) of neck (Lannelongue). 
the neighborhood of the pharynx and larynx, and along the large ves- 
sels; they often have prolongations adhering to the muscles, the vessels, 
the thyroid cartilage, and hyoid bone, and even the vertebral column ; 
they may be single or multiple, resembling a bunch of grapes. They may 
take a sudden and unexplained rapid course and become very large (Fig. 
108). 
Serous cysts have been confounded with dermoid, mucous, or 
branchial cysts, although they do not, like those cysts, occupy a definite 
region corresponding to the branchial fissures: the neck is their seat of TUMORS OF THE NECK. 
237 
predilection, and they serve as a type of their kind. When they are 
single or unique, they are almost always on the median line and on the 
left side ; they occupy principally the antero-lateral surface of the neck 
(Fig. 108). 
Sebaceous cysts or atheromatous cysts are only truly such when the dermoid 
structure of the cyst-walls can be demonstrated. They may attain the size of a 
fist; when lateral, they occupy mostly the region of the sterno-mastoid; when 
median, they occupy mostly the supra- and infrahyoid regions. 
Sanguineous cysts are at times connected with the anterior jugular 
vein; they contain a reddish fluid, which characterizes them upon 
exploration ; occasionally they remain in connection with vessels. They 
Fig. 109. 
Dermoid (ad-hyoid) cyst at base of tongue (Marchant). 
are emptied by pressure, but they refill rapidly; they must not be 
taken for aneurisms when the vessels impart pulsations to them. Hem- 
orrhagic sanguineous cysts are due to intracystic hemorrhage. Punctures 
and incisions are sometimes followed by intracystic hemorrhage, which 
may ultimately end fatally. 
Dermoid cysts are frequent here: the cyst may be attached to the 
trachea. These cysts are not bursal cysts: the epithelial lining shows 
they are congenital. They are all congenital, but they may not become 
manifest except at a later period, especially at puberty. Lateral 
branchial cysts usually occupy the region of the sterno-mastoid. 
Median branchial suprasternal cysts sometimes penetrate into the 
mediastinum. Median thyro-hyoid cysts often take on a rapid growth at 
puberty or after a confinement: they are often opened by mistake, and 
this is followed by a persistent fistula with mucous secretions (Fig. 109). 238 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
Fibroma is rare; it rises from the fibrous layers. Congenital 
branchial fibro-chondroma of the neck is seen in all regions of the 
branchial arches. It occupies almost always the external orifice of a 
congenital fistula, a little above 
the sterno-clavicular articulation. 
Myxoma and myoma are rare : one 
case of chondroma is on record, fol- 
lowing chondroma of the scapula. 
Those independent of parotid and 
lymphatic nodes are very rare; 
some tumors are very large; they 
may adhere to the vessels and to 
the deep structures (Fig. 110). 
Fig. 110. 
The condition of the skin is im- 
portant to determine: when distended 
by a large tumor a portion of it must be 
dissected along with the tumor to pre- 
vent redundancy of the flaps; when the 
skin is adherent, it should be also 
removed. The tumor margins must be 
next delineated: when circumscribed or 
limited, it is a favorable sign, because 
the tumor will be easier to remove along 
a well-determined line of dissection with 
safety and in its entirety; when the 
margin is diffused, it is a most unfavor- 
able feature, because of the uncertainty 
of the line of dissection and the absence 
of all certainty of removing all the 
involved parts. 
The non-adhesion or the adhesion 
of the tumor to the bones is important to determine: when the tumor is movable, 
it must be determined whether it is clear of the important structures—i. e. if the 
vessels, nerves, and special organs. 
It is prudent also in those cases to endeavor to locate the large vessels and to 
pass a provisional ligature under them before dissecting too close to the dangerous 
points. This provisional ligature is removed after all the bleeding has been con- 
trolled, or it may be decided to convert it into a permanent one. When the tumor 
is adherent to the bone, if it be clear of important structures, it is again favorable, 
as it may be enucleated with little risk. 
Enormous diffuse lipoma of neck (Jeannel). 
Infrahyoid Region. 
Congenital Malformations.—Tt is in the lower part of the region 
that the orifices of the branchial congenital fistula? of the neck are most 
frequently met, near the head of the clavicle ; they may also be met in 
the thyro-hyoid region. 
In hanging the compression very often bears on the base of the 
tongue, and the larynx, vessels, and nerves are not injured. In strangu- 
lation the traumatism is applied upon the larynx and the trachea, which 
may be torn by the fingers or the rope ; all the structures are more or 
less torn. In some cases lesions of the skin of the neck, of the trachea, 
and of the larynx may cause inhibition of the heart, of the respiratory 
organs, and of the brain. It is especially in cases of traumatism of the 
anterior region of the neck that we observe a complete loss of con- 
sciousness and a respiratory and cardiac syncope. This is what takes WOUNDS OF NECK. 
239 
place in cases of death through incomplete hanging, which does not 
prevent the passage of air through the respiratory passages. In such 
cases the red blood of the arteries continues red in the veins, whereas in 
death by true asphyxia the blood becomes rapidly black in the arteries. 
Suicidal wounds are the most frequent; they are seldom punctured 
but are usually incised wounds; are most frequent at the point of the 
thyro-hyoid ligament or below it; they are lacerated, jagged, and deeper 
on the left side, and are usually directed from left to right and 
obliquely downward or transversely across the neck; the large muscles 
are seldom injured. Usually the suicide, throwing his head back, cuts 
too high; the trachea and the rigidity of the sterno-mastoid protect the 
vessels. If the head is too bent, the larynx, the trachea, and the sterno- 
mastoid also protect the vessels. There is usually a single gash. These 
wounds are more commonly fatal than the other wounds, because the 
victims are usually intoxicated or are laboring under delirium tremens 
or insanity : these patients should be watched closely, because they often 
tear away their dressings and die of hemorrhage. These wounds some- 
times present much hemorrhage, although none of the larger vessels are 
hurt, except the anterior jugular vein : there are cases on record where 
air has penetrated into it and to the heart, causing death. The edges 
of these wounds are often much separated and have a tendency to roll 
in, on account of the action of the fibres of the plastysma; coaptation 
therefore needs more care. 
Penetrating wounds above the larynx are less dangerous than those 
of the larynx and of those below it; the lower the wounds the more 
dangerous they are. Wounds throuqh the thyro-hyoid membrane pene- 
trate into the pharynx, injure the epiglottis, the aryteno-epiglottic folds, 
the cartilages, the vocal cords; they are less dangerous than below, 
because they allow feeding; they are more liable to suppuration. 
Wounds of the larynx are comparatively frequent, because of its promi- 
nence : they are usually very dangerous; they are also easily diag- 
nosed by the rushing sound of the air passing through. They should 
be treated like those of the trachea. Wounds of the trachea are 
commonly followed by great hemorrhage, because of the large vessels 
around it, which may also have been wounded by the same cause. When 
the severance is incomplete, there is slight gaping; when the section is 
complete, the lower end is drawn in deep at each effort of inspiration, 
and the soft parts cover up the orifice, causing suffocation. In all cases 
keep the blood and foreign substances out of the respiratory tract until 
hemorrhage is checked. Rose’s position may be of assistance. In 
incomplete wounds there is slight gaping, and the wound should not be 
stitched; the head should be flexed on the chest and fixed in that posi- 
tion by a liquid-glass bandage. In complete wounds, when longitudinal, 
there is little gaping. In complete transverse wounds the retracted lower 
end should be searched for and a strong thread passed deeply through 
it. An attempt at stitching should be made ; if it fails, a tracheotomy- 
tube should be placed in it; the tube should be longer than the ordinary 
one, because the swelling may lift it out of the trachea; the head should 
also be kept flexed; a moist cloth should be placed over the tube; the 
room should be kept warm, at about 70°, and a vessel with boiling 
water should keep the atmosphere moist—all this to avoid bronchitis and 240 
SURGICAL DISEASES AND INJURIES OF TIIE NECK. 
pneumonia. Later we should be mindful of the exuberant granulations, 
which may obliterate the canal. 
Wounds of the pharynx and oesophagus are usually made through 
the side of the neck by balls, knives, etc.; they cause much pain, 
spasm, hiccough, dysphagia, more or less suffocation; there is escape 
of food through the wound if this be of a certain size; the thirst is 
great; the patient should be fed by enema ; if the use of the oesophageal 
tube becomes necessary from insufficiency of the rectal alimentation, it 
should not be left in place, but introduced each time. In incised wounds 
stitch immediately ; in lacerated wounds let the wound granulate. 
Penetration of the respiratory tract is recognized by cough, bloody 
expectoration, hissing or boiling sound. The secondary dangers are 
inflammation of the larynx, oedema of the glottis, bronchitis, pneumonia, 
abscesses and purulent dissections, emphysema, aphonia more or less 
complete, dysphagia: secondary hemorrhages are common and serious 
complications. In all injuries with solution of continuity of the 
mucous membrane the most frequent source of death may be due to 
mediastinal emphysema and inhalation pneumonia. 
Wounds of the neck parallel to the longitudinal fibres of the muscles are more 
apt to be followed by emphysema. The remote effects and sequels may be exuberant 
granulations, causing dyspnoea; cicatrization, producing strictures of the larynx, 
trachea, and oesophagus ; persistent fistulm; paralysis, due to inflammatory thick- 
ening, which may disappear later, or due to injury of recurrent nerves or the 
pressure of a bullet. All these complications should be treated here as elsewhere. 
Dislocation of the hyoid bone is very rare. There is one case 
(Gibbs) in which the dislocation was muscular: it was accompanied by 
a peculiar click on the left side of the neck and a sensation of choking; 
examination showed displacement of the left horn of the hyoid bone; 
reduction was effected bv throwing the head backward toward the right 
side, so as to stretch the muscles of the neck, and then suddenly 
depressing the lower jaw, thus bringing the depressors of the hyoid bone 
into action. All the following fractures are usually due to violent con- 
tusions. 
Fracture of the hyoid bone is rare, but it is well known; its site 
is usually the great horn, near the body; it may be unilateral or 
bilateral; it is characterized more or less by hoarseness and dysphagia, 
according as it is without or with displacement, and without and with 
deformity. It is accompanied by more severe symptoms, especially 
when swallowing fluids, which pass into the larynx because of the 
imperfect action of the epiglottis; it is reduced by using the fingers 
inside. 
Fractures of the larynx are less rare than fractures of the hyoid 
bone ; they are due to great violence ; they are usually accompanied by 
much pain and suffocation, often calling for immediate reduction or for 
tracheotomy. Each cartilage may be fractured by itself; the thyroid 
is most frequently the site; fractures without displacement are not so 
grave. 
Fracture of the thyroid cartilage is more common in old people, 
because of the ossification of the cartilage. Fracture of the cricoid is 
more dangerous than others, perhaps because of its small size, which 
causes slight displacement to be followed by serious obstructions. INJURIES TO THE TRACHEA. 
241 
Fracture or subcutaneous rupture of the trachea without actual 
wound has been observed after great traumatism ; they are less frequent 
than the others ; they present the same symptoms and indications as the 
fracture of the larynx, but the lesion is lower down. The traehea 
should be opened below the fracture, and a long tracheotomy-tube 
introduced; when the fracture is low down, the lower end should be 
hooked, raised, and sutured to the skin or upper fragment. 
Spontaneous ruptures of the trachea, due to violent efforts, are 
accepted by some. All these fractures are more serious if accompanied 
by displacement which obstruct the air-passages. 
The symptoms are those of obstruction and shock, plus those of frac- 
tures in general—crepitation, abnormal mobility, plus also aphonia, dys- 
phagia, emphysema. The fragments should be replaced by external and 
internal manipulations; if necessary the parts should be incised through 
and the fragments stitched. Tracheotomy is often indicated: it is well 
to perform the operation before grave symptoms develop, because these 
sometimes come on so suddenly that the patient may succumb before the 
surgeon can be had to operate. 
Laryngo-tracheal abscess causes much dyspnoea, and shows a tend- 
ency to extend down along the trachea. 
Such lesions are often the starting-points of the peculiar broad or diffuse cel- 
lulitis of Dupuytren; they are sometimes secondary to cellulitis of the substerno- 
mastoid connective tissue; they are at times produced by cold, by crying loud, so 
that the public criers and street-venders are most often affected ; usually it is women 
in bad health that are most commonly affected; men very seldom. These diseases 
are usually connected with some general diathesis; they may extend from the ear 
to the clavicle and from the nucha to the larynx; they may involve also the other 
side. The pus is infiltrated in the muscular interstices and the connective tissue; 
gangrene is not infrequent. The pressure symptoms are very great. This descrip- 
tion resembles that of the disease called diffused cellulitis of Gray-Coley and 
Hannon, which they say is mostly limited to the anterior region of the neck—is 
due to cold and humidity, and resembles erysipelas: it gives the sensation of hard 
oedema without fluctuation. The inflammation of the infrahyoid region gives rise 
to greater risk of oedema of the glottis and extension to the mediastinum. 
Bursal cysts develop in the serous bursse found in front of the hyoid 
bone, Adam’s apple, the cricoid cartilage; they are usually called hy- 
groma or hydrocele of the neck; they form the group of the thyro-hyoid 
cysts. All the tumors of this region present these peculiar features: 
first, they give rise to more grave pressure symptoms than anywhere else ; 
second, they are usually in the way of tracheotomy, and relief can only 
be found by operating; they often penetrate behind the sternum, and in 
order to follow them it is necessary to remove the upper part of the 
sternum. These retrosternal tumors should be explored with the syringe 
first; when fluid they should be treated by incising and packing; when 
solid they should be explored by an incision, and, when possible, enu- 
cleated. Great care should be taken not to excise any of the deeper 
parts of the walls, because the large veins of the region are often adher- 
ent to them, and are thus severed, when uncontrollable deadly hemor- 
rhage supervenes; the walls should not lie incised even between the two 
forceps or ligatures, because if these large trunks are involved, the inter- 
ruption to the circulation may be too serious. Most of these cases are 
operated for palliative purposes of a temporary nature. 
In cases of injuries and inflammations about the neck the great dan- 242 
SURGICAL DISEASES AND INJURIES OF TIIE NECK. 
ger is from suffocation due to the obstruction of the respiratory tract 
from swelling or oedema of the glottis, or from displacements in cases of 
fractures or ruptures. These accidents often come on so suddenly that 
the surgeon has not always time to reach the patient and operate in season 
to save the life; therefore precautionary anticipating tracheotomy should 
be performed at the least evidence of serious suffocation. It can be 
well done under cocaine; it will relieve the existing symptoms of dys- 
pnoea, will prevent their aggravation or the death of the sufferer, and 
will not add to the risks if properly and regularly done. The tube 
should be long, because of the existing inflammation, and because the 
inflammation that will follow may lift the tube out of its proper posi- 
tion and render the procedure useless, deceptive, and dangerous—because 
it will lead to the belief that the operation has been done with no 
benefit. 
When fractures or ruptures are strongly suspected, after the threatening suffo- 
cation has been removed by tracheotomy it is important to examine thoroughly 
and repeatedly with the laryngoscope to ascertain if there is any obstruction visible 
with the instrument; if none is seen, and yet a fracture is strongly suspected, the 
surgeon must explore directly—cut down to the hyoid bone, the thyroid cartilage, 
the cricoid, the trachea—and remedy all deviation causing obstruction, using cat- 
gut or silver stitches and small silver bands as splints or pins inserted through the 
fragments. It is of paramount importance that there should be no impediment 
when the tracheotomy-tube is removed; if all these efforts have not been made, 
the patient may have to wear a tracheotomy-tube for life or submit to the above 
manoeuvres after the fractures or ruptures have united—i. e. under the greatest 
disadvantages. 
Ill cases of growing aneurisms at the root of the neck, in view of the 
distressingly painful condition of these patients and of the fact that they 
are doomed, the surgeon is justified in resecting the upper part of the 
sternum as an exploratory operation. When it is found that the aneur- 
ism is one of the origin of the right subclavian, and that the innominate 
is not dilated beyond an inch and a half, it is advisable and justifiable to 
make the desperate attempt of tying them by applying two or three 
strong catgut or kangaroo ligatures, with as much of a bloodless space 
as possible between, and tighten them as much as deemed safe without 
rupturing the coats. The same remarks apply to the left carotid and 
subclavian if they are not dilated beyond an inch in diameter. 
In cases of tumors of the infrahyoid region penetrating down behind the 
manubrium, the same resection for exploring purposes is recommended, with a view 
to total removal of the tumor if it is found possible. 
The location of a disease in the thyroid body is recognized by the fact that the 
organ ascends and descends with the larynx during deglutition. Another way to 
determine if the tumor is of the thyroid body is to seat the subject with the head 
stretched back and resting; then with the thumb communicate a slight but brisk 
movement from below upward: if the tumor budges, it is because it is not adhe- 
rent or is little so. 
The Thyroid Body. 
Congenital Malformations.—Absence of the thyroid body has been 
observed occasionally in whole or in part, and congenital atrophy has 
been occasionally observed. 
Congenital hypertrophy may affect the whole region or one side 
only, or even one part. There are also cases of aberrant thyroid, due THE THYROID BODY. 
243 
to the separate development of • some of the lobules of the organ; these 
may be single, double, or multiple, or unilateral, as low down as the 
sternum or even behind the manubrium. 
Acquired atrophic malformations are due to injuries, to diseases, 
and to surgical operations destroying or removing the body in part or 
in whole. The total destruction or removal of the thyroid gives rise 
to a peculiar train of symptoms. The immediate sequels of total 
destruction of the entire thyroid by thyroidectomy are acute mania, 
tetany, hysteria, myxoedema, or cachexia strumapriva. (Vide Vol. I. 
Chapter VIII.) 
Few who have been operated before full growth escape; the signs begin to 
show on the third or fourth day; there are paleness, lassitude, weakness, ansemia; 
swelling and coldness of the extremities; muscular tremor; swelling of fingers 
first, then of the rest of the body, mostly apparent in the face and neck; this swell- 
ing is not oedema; it is hard and elastic, without pitting; the face presents the 
characteristics of this swelling in the highest degree; there are also cephalalgia, 
vertigo; the pulse is small. In tetany there sometimes exists such swelling, but 
it is not infectious. The complication is prevented by not removing the whole 
mass—i. e. by leaving a portion, especially that which is adherent to the trachea. 
The best treatment is by thyroid extract or the transplantation of the thy- 
roid body of the sheep into connective tissue or the abdomen. The changes are 
relative to the alteration of the mucin and other metabolic waste. Pachydermic 
cachexia (or myxcedema of English writers) resembles myxceedma, and results 
from the destruction of the body by disease. 
Wounds of the thyroid body are apt to be serious, on account of the 
great vascularity of the organ and its friability ; the bleeding is usually 
great, especially if breathing be obstructed or laborious. 
Treatment of hemorrhage is difficult, because of the friability 
which will not allow a ligature to hold tight enough to arrest the bleed- 
ing with safety against secondary hemorrhage. The same remarks 
apply to the forceps left in situ. Deep suturing succeeds best, or a 
chain ligature or a purse-string ligature; a pin or needle suture, such 
as is used for hare-lip, sometimes succeeds ; pressure is not borne ; it is 
useless to ligate the nearest trunk, because the other vessels will keep 
up the hemorrhage. When the bleeding is serious, tracheotomy, if prac- 
ticable, sometimes stops the hemorrhage by relieving its congestion; in 
spite of all, death is sometimes the result of hemorrhage. 
Congestion or hypercemia of the thyroid body is frequent on account 
of its great vascularity—i. e. simple congestion independent of any 
forming or formed goitre. 
The causes are all internal; the physiological are—efforts of all 
kinds, menstruation, coition, pregnancy, accouchment; the most com- 
mon pathological causes are—impediments to the venous circulation, 
the existence of infectious diseases, intermittent fever, endemic influ- 
ences : repeated congestions cause goitre. 
The treatment consists in removing the cause and in the treat- 
ment of congestion in general. When suffocation occurs, save during 
pregnancy, the trachea should be opened. 
Thyroiditis, sometimes called inflammatory goitre, acute goitre, stru- 
mitis, is usually unilateral. The external causes are the various trau- 
matisms, infection of an ordinary wound, the influence of cold, etc. 
The internal causes are an effort causing a luematoma, the influence of 
rheumatism, a pre-existing infectious disease, especially pyaemia, puer- 244 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
peral fever, malaria. The pre-existence of a congestion or tendency to 
a goitre is a great predisposing cause ; if it discloses itself in a manifest 
goitre, small or large, it is not a true thyroiditis, but a strumitis. 
Suppurating thyroiditis is always of a microbic origin. The pathologi- 
cal peculiarities are that death may take place before suppuration has 
been established: when formed, the pus may fuse in the mediastinum, 
along the respiratory tract, and the oesophagus. 
The peculiar symptoms are great thirst, owing to difficulty in and 
aversion to drinking on account of the pain in swallowing; raising at 
each pulsation of the carotid arteries; cephalic symptoms, due to the 
pressure upon the veins; great congestion of face, and epistaxis due to 
the same causes; nausea and vomiting, due to pressure upon the pneu- 
mogastric. 
The course is continuous; the duration about fifteen or twenty 
days. The terminations are by persistent indurated spots or by sup- 
puration ; sometimes abscesses are formed ; fistulous openings, single or 
double, occur; the abscesses may open into the larynx, trachea, 
(esophagus, or may fuse in the mediastinum; gangrene of the thy- 
roid sometimes takes place. 
The prognosis of thyroiditis is grave. 
Tumors of the Thyroid Body.—Cystic tumors are represented 
especially by hcematoma following an injury or due to a hemorrhage in 
a pre-existing cyst, either from a traumatism or from a puncture with 
a too large needle, and removal of all the liquid or enough to destroy 
the equilibrium of the pressure. Pulsation in the thyroidal tumors is not 
uncommon, owing to the pressure on the great vessels. Congenital 
mixed, cysts are the most common ; they contain thyroid vesicles, pave- 
ment epithelium, cartilage, muscular fibres. A peculiarity of the 
thyroid cysts is that, whether small or large, they may from sudden 
congestion or rupture cause suddenly great dyspnoea, which may be 
rapidly fatal. Cystic growths of the thyroid should be enucleated, as 
this avoids any possible injury to the recurrent laryngeal nerve, and 
also avoids the possibility of cachexia strumapriva by leaving all the 
thyroidal tissue that is not diseased. 
Solid tumors are represented mostly and almost entirely by goitres : 
although they sometimes contain cavities or cysts, yet their walls are 
usually so thick they are considered as solid tumors, and are described 
with such. The great majority are simple hypertrophies. 
Goitre. 
This is an enlargement or hypertrophy of the thyroid body without 
structural changes; it may involve the whole region or be unilateral or 
bilateral; it is more frequent on the right side. 
The causes of goitre in general are not yet known. The alterations 
as regards size and shape are variable. The microscopic alterations 
consist in cavities, channels, and compartments lined by a pavement or 
cylindrical epithelium. This form of goitre is the primordial form ; 
it is epithelial or follicular : the other forms of goitre are only modifica- 
tions of it. 
The symptoms are those of a hypertrophied organ in general; the THE THYROID BODY. 
245 
peculiar symptoms are—the shape of a horseshoe; the movements 
following the larynx; the veins developed on the surface; the peculiar 
deformity of the region; the pressure-symptoms on the cerebral and 
facial circulations. 
The course is usually very slow, and sometimes irregular. 
The duration is ordinarily very long. 
The prognosis becomes serious with the degree of pressure-symp- 
toms and the complications. 
The true treatment of goitre consists in extirpation, especially if 
it grows and if the pressure-symptoms are serious. We must bear in 
mind that an apparently innocent goitre may suddenly enlarge and 
cause suffocation or even sudden death. 
The internal treatment consists in long-continued thyroid-feeding, which will 
diminish the size of a goitre and even bring on a condition of atrophy, so that the 
danger lies in abolishing the functions of the thyroid. Sodium phosphate has the 
same effect and consequences. 
We should be careful in using anaesthesia if there are already signs 
of pressure; the use of morphine or cocaine is preferable. 
Operation with cocaine is often possible ; the pain does not seem to 
be beyond endurance; the dangers of the operation are much lessened 
without anaesthesia; there is much less turgescence of the veins than 
when an anaesthetic is used—none, of course, from coughing, vomiting 
—and the dangers of complications are thus diminished. The incision 
should extend from one side of the neck to the other in a very sharp 
and long curve, with the convexity downward toward the sternum. The 
upper part of the tumor would better be attacked first, and the upper 
vessels tied, then the middle or the inferior; the hemorrhage is reduced 
to a minimum by careful haemostasis by means of forceps and double 
ligature of the larger vessels before incising between the ligatures. 
When the inferior thyroid artery is being dissected and tied, by engaging the 
patient in a conversation for a few minutes the possibility of including the recur- 
rent laryngeal nerve in the ligation is avoided, as the altered voice immediately 
warns the surgeon of the danger. At the lower right angle is the portion which 
often penetrates into the mediastinum behind the sternum; there exist usually at 
that point large veins. When possible lift the body from its bed and encircle 
the pedicle with an elastic tubing before enucleating, as recommended by Rose and 
Poppert. The dangers are hemorrhage and asphyxia by blood falling into the 
trachea when it is torn: to avoid these perform preventive tracheotomy when pos- 
sible. In the hypertrophied thyroid the arteries are larger than in the normal, 
but are in their usual situations. Be careful again not to tear the trachea: if this 
happen, introduce at once a long tracheotomy cannula. 
In exophthalmic goitre Kocher resorts to ligature and ties only three arteries. 
In one case when four arteries were ligated tetany set in immediately. Intracap- 
sular enucleation is the safest, but is not always feasible. When the difficulty of 
tracheotomy is due to pressure, division of the isthmus may afford relief. 
Aberrant goitres are those found in the supernumerary thyroid 
bodies—i. e. those in the lobules developed independently and which 
failed to unite with the rest of the body: they are sometimes called 
ganglionic goitres, because they resemble hypertrophied lymph-nodes. 
Peri- and retrovascular goitres are those which send processes around 
and behind the large vessels of the neck. Colloid goitre is one that 
attains the largest proportions. 
Exophthalmic goitre, or Basedow’s or Graves’ disease, is accom- 246 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
panied by protrusion of the eyeball and tachycardia, with irregular, fre- 
quent loud sounds; the heart is dilated; there is also alteration of the 
normal sounds ; the arteries of the wrist and head throb. These symp- 
toms are due to changes in the middle and lower ganglions of the sym- 
pathetic. Suppuration is very rare. There is a surgical exophthalmic 
goitre, due to the pressure upon the nerves, purely mechanical and very 
distinct from Graves’ disease. In goitre with a feeble heart and a weak 
pulse great care should be exercised in operating. Inflammation of a 
goitre is called strumitis: it is much more frequent than thyroiditis or 
inflammation of a normal thyroid; it is serious because of the enlarged 
condition of the organ. Tracheotomy may be performed for relief until 
the pus is located and evacuated by incisions or by dilatation upon a 
guide. 
All the other solid tumors of the thyroid body are rare. Sarcoma is 
more frequent, and has been observed in all its varieties. The difference 
between hypertrophy and sarcoma is that usually the hypertrophy has 
the same shape as the gland, whereas the sarcoma has not. Carcinoma 
is also among the infrequent tumors of the thyroid outside of goitre. 
It is sometimes connected with the oesophagus or larynx; it may be 
metastatic from the cancer of some other part. The primitive cancer is 
the one here considered: it is rare, and is met especially in goitrous 
countries. 
The Suprahyoid or Submental Region. 
Incised wounds when transverse usually gape a great deal, but very 
little when longitudinal; usually the suicide, throwing his head back, 
cuts higher than he intends in the suprahyoid region, so that the borders 
of the stretched sterno-mastoid protect the vessels. The penetrating 
wounds open the cavity of the mouth, injure the tongue and epiglottis; 
there may be suffocation due to the blood or other foreign substances, or 
to the tongue or epiglottis falling back and occluding the larynx ; there 
is usually much hemorrhage from the wounding of the lingual artery. 
More than in all injuries of the neck, we meet here with swelling and 
oedema of the aryteno-epiglottic folds, which are directly injured. The 
gaping is especially very great when the head is thrown back ; the saliva 
and food pass out of it during deglutition. Wounds of the epiglottis 
cause much suffocation, difficulty of speech, of deglutition, coughing; 
thirst is a common symptom. Lacerated wounds are observed in sev- 
eral cases of hooking of the chin. 
Congenital branchiogenic cysts of the region of the hyoid bone 
extend sometimes into the mouth and resemble ranula, but they are 
independent of the submaxillary and sublingual glands. Simple serous 
or suprahyoid grenouillettes have been studied only recently : they are 
usually seated underneath the cervical fascia ; they are very often an 
extension of a sublingual cyst or grenouillette through the muscles of 
the floor of the mouth. Dermoid cyst# sometimes remain dormant for a 
while, and then become apparent; if by the history the cyst may be 
traced to infancy, it is a dermoid cyst. 
Foreign bodies in salivary passages are most frequent in Wharton’s 
duct; they may be bristle, fish-bone, straw, hair of a tooth-brush. There 247 
THE PAROTID REGION. 
are pain, swelling of the gland, abscess, fistula. They may give rise to 
salivary colic. 
The treatment is that of all similar cases. 
All the other tumors are rare and present no peculiarities. 
Hypercemia is represented here by the submaxillary mumps, seated 
in the salivary glands, very rarely existing independently, and usually 
associated with parotid mumps. 
Inflammation under the form of phlegmon is very common in this 
region. It is usually due to lesions of the face, mouth, tonsils, and 
especially dental caries, with periodontitis. 
Inflammation with abscess of the salivary gland itself is extremely rare. 
Osteo-periostitis from diseased teeth is often confounded with adeno-cel- 
lulitis; in the former the swelling corresponds to the body and to the 
border of the maxilla; its tendency is toward the face and the masseter 
portion of the cheek; the vestibule is painful and sometimes fluctuant. 
In adeno-cellulitis the swelling exists below the maxilla and has a tend- 
ency toward the neck. Chassaignac’s subangulo-maxillary adeno-cellii- 
litis is met with beneath the angle of the jaw, and is due to the difficult 
eruption of the wisdom tooth. 
Ludwig’s acquired or infectious submaxillary angina is characterized 
by excessive swelling and pain ; the tongue is swollen and immovable; the mouth 
is distended in front; there is difficulty of swallowing ; it may terminate in gan- 
grene ; it often ends in death. 
The treatment of these abscesses consists, of course, in evacuating the pus 
as soon as possible. Incision should be made under and parallel with the inferior 
border of the maxilla, so that the cicatrices will not show; by using the method 
of dilatation on a guide the evacuation takes place wffien the exploring needle has 
located the pus, and there is no cicatrix of any consequence remaining. 
Retropharyngeal abscesses often point toward this region, although they 
may fuse down into the mediastinum; in the former case the large vessels are 
between the pus and the surgeon’s knife. It is best to try and evacuate through 
the mouth, to avoid the course of the large vessels and nerves. An incision on the 
middle line of the pharynx, if it will accomplish the object, is preferable, as safer ; 
it is well then to place the patient in Rose’s position to prevent the entrance of the 
pus into the larynx. 
Salivary calculi are peculiar to this region; they give rise to pain 
and swelling; sometimes abscesses are followed by fistulous openings, 
temporary or permanent. The calculi sometimes occupy the centre of 
gland or the deep surface, and the most important symptoms, as also 
the fistulous openings, are in the mouth. They are diagnosed by search- 
ing carefully for the opening of the fistula and probing it, when the pecu- 
liar click will be felt; if necessary, a needle thrust deeply through the 
gland in several directions will strike the calculus if it be present. 
The Parotid Region. 
Congenital absence of the parotid and atrophy of the gland are 
very rare. However, occasionally subjects are seen with a deep hollow 
between the ramus of the jaw and the mastoid process, showing the 
partial atrophy at least of the gland. 
Injuries of the parotid region are rare; they are grave, on account 
of cicatricial disfigurement and injuries to the facial nerve and to Sten- 
son’s duct. Incised deep wounds are most serious. 248 
SURGICAL DISEASES AND INJURIES OF TIIE NECK. 
The diagnosis of the penetration of the gland rests upon the escape 
of saliva. When the wound is narrow, the hemorrhage, and later the 
suppuration, prevent the diagnosis; if the pus is very liquid, it is prob- 
able the gland is seriously injured. To prevent fistuke, stitch tight and 
procure rest of jaw. Deep wounds are more serious, because of the pres- 
ence of the temporo-maxillary vein, which becomes the external jugu- 
lar ; also of the other deep vessels. 
The bleeding is profuse and sometimes terrific: it should be at once stopped 
by plugging; then a provisional loop ligature should be applied on the common 
carotid close to the bifurcation ; the bleeding points should then be ligated. If 
this fails, it should be determined with care which vessels furnish the hemorrhage. 
If the external carotid, ligate it; if the internal carotid, ligate it separately, or 
ligate the common carotid at the very bifurcation to prevent the return through 
the collateral circulation; if the jugular vein is injured, ligate it as high up as 
possible, at least above the facial and lingual, or ligate these. After the ligation 
or ligations have been done, the accidental wound should be packed tightly. 
Hyperaemia of the parotid is here represented by the disease called 
mumps. It is considered a specific infectious disease; it is contagious 
in schools ; it is most serious in spring, in damp and cold weather; young 
male children are more commonly liable; sometimes it follows orchitis, 
but it is usually the reverse. 
The pathology is obscure. 
The most remarkable symptoms are pain and swelling without red- 
ness or heat, softness of the part; no induration; no fluctuation ; the 
pain is increased by biting, chewing, swallowing; there is little or no 
general reaction. The beginning is often sudden, also its termination ; 
it sometimes moves suddenly to the testicles, ovaries, or breasts. 
The duration is about ten days. 
Termination by resolution is the rule; it is altogether exceptional 
when it suppurates. 
The treatment consists of soothing liniments and keeping the parts 
warm. 
Acute parotiditis is a comparatively rare disease. Its cause may 
be mumps (rare), a debilitated state of the system, an infectious disease 
(typhoid fever, sepsis); it may be complicated with ear, eye, tonsil or 
brain syphilis, but it is very rare. A pathological peculiarity is that 
the capsule of the gland prevents the pus from coming to the surface 
quickly. 
The symptoms are those of deep cellulitis, with the addition of 
the general symptoms due to the lesion which is the cause of the 
parotiditis. It terminates almost always by suppuration ; the pus may 
open in the ear, pharynx, vessels, down in the neck and chest, in the 
space behind the pharynx; it may terminate by several successive 
abscesses, it may terminate also by gangrene. 
The prognosis is most grave. 
The treatment consists in keeping the mouth disinfected and in an 
early evacuation. 
In superficial abscesses be mindful of the course of the facial nerve and of Sten- 
son’s duct; in deep suppurations, of the external carotid: in these cases follow 
Hilton’s method or dilatation upon a guide. 
Fistulae of the parotid are not very common. 
The prognosis is bad, because they are often difficult to cure. OPERATIONS ON THE PAROTID REGION. 
249 
The treatment consists in local cauterization—if insufficient, in 
making a large hole in the region and closing the surface opening by a 
plastic operation; in persistent cases, in destroying the parotid. 
Tumors of the Parotid.—The lymphatic nodes, while not situated 
in the parotid, may present almost all the tumors that develop in the 
salivary gland; they are called supraparotid tumors; they are usually 
movable, whereas the tumors developed on the parotid gland are not. 
Solid tumors of the parotid may be of all the varieties elsewhere 
found. Chondroma forms 30 per cent, of the tumors of the region. 
Sarcoma, together with fibroma and cystoma, is about equally often 
present. Carcinoma represents about 45 per cent, of all the tumors 
of the parotid region. Usually they are mixed tumors, in which the 
epithelial element has taken a great development; they may be 
secondary to similar tumors originating in the pharynx or on the face. 
Primary carcinoma is rare. Encephaloid develops at forty-one, on the 
average. Pulsating encephaloids are very rare. Melanotic cancer is 
very rare ; it usually involves the lymphatics. Scirrhus usually de- 
velops at sixty or seventy. Mixed tumors are commonly those called 
simply chondromata; they usually remain limited to the parotid, and 
do not invade the other regions; they may become very large, so as to 
affect the mastication ; some have a rapid course, some a slow one ; they 
may degenerate into sarcomata ; they return rarely if operated in the 
first period; they return often if operated in the second period; gener- 
alization is very rare. 
Tumors special to the parotid region are represented by the sali- 
vary calculi developed in the parotid ; they are rare in the gland itself; 
they are said to be more frequent in males and in adults ; also to be due 
to the inflammation of the duct-radicles which retard the flow of the 
saliva ; also to changes in the chemical composition of the saliva. They 
usually cause pain, inflammation, and an abscess, which upon opening 
leaves a salivary fistula: using the probe through the opening or by 
penetrating the gland deeply with a needle, the calculus is felt; they 
may cause atrophy of the gland by sclerosis. They should be removed 
through an incision. 
Operations on the Parotid Region. 
The possibility of extirpating the whole parotid has been much discussed, but 
it presents no practical or clinical value. When the gland is diseased, the disease 
must be removed, whether it affects the whole gland or not. A partial disease of 
the gland with prolongations is as bad as, if not worse than, a disease affecting the 
whole gland without such processes. The dissection should proceed from below 
and behind, upward and forward; the external carotid should be located and 
ligated or clamped, otherwise it might be cut several times. When the dissection 
leads into the deep parts, the patient’s mouth should be opened, as this increases 
the size of the parotid cavity and renders the deep dissection easier by affording 
more room. A previous permanent ligation of the external carotid might be done, 
or a provisional loop ligature applied to the bifurcation, so that if it should 
become necessary to ligate the internal carotid, the same incision will answer for 
all purposes. In penetrating the region the dangerous structures are at the 
entrance, and in front, to the inner side of the head and neck of the condyle; 
more deeply, they are on the posterior wall. Some tumors of considerable size, 
and sometimes extending to the pharynx, are removed with little difficulty and 
little hemorrhage if the adhesions are loose ; whereas adherent tumors, even of 250 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
small size, are fraught with danger. The safe plan is to proceed as long as the 
adhesions with the surrounding structures are easily broken, and to stop as soon 
as they become too resistant and as we approach the deep dangerous structures, 
which may be adherent to the tumor. Then the cleared part of the tumor should 
be cut off. It is a remarkable fact that often the stump left will, in growing again, 
become more superficial, and it is sometimes possible to remove the stump entirely 
by a second operation. 
The Lateral Region of the Neck. 
Congenital malformations are represented in this region by the 
orihees of the branchial fistulae situated most commonly along the lower 
part of the anterior border of the sterno-mastoid; also by the congeni- 
tal deformity of the sterno-mastoid, called hsematoma of the sterno- 
mastoid and congenital torticollis ; also by the congenital atrophy of the 
same muscle. Acquired malformations comprise the various forms 
and varieties of torticollis and the deformities due to cicatrices. Cica- 
trices of the neck are most objectionable especially when affecting exposed 
parts. 
Penetrating wounds of the external jugular, of the internal 
jugular, and the carotid arteries are most serious injuries. They may 
all give rise to circumscribed or diffused haematoma. When this is of 
some size and stationary, it must be aspirated or incised. When it pul- 
sates and grows, it is because a traumatic aneurism has formed, and the 
wounded vessel, vein or artery, must be ligated above and below at the 
injured point. When the penetration is comparatively small the sac 
may be incised at once, after making as good pressure above and below 
as possible. When the puncture is iarge and there is risk of the patient 
bleeding much before the proper ligatures are secured, a provisional 
loop ligature must be applied below the wounded point. When the 
wound or the swelling is very low down, enough of the sternum must 
be resected to reach the root of the carotid and the innominate, and 
apply there the provisional loop ligature. Considering the gravity of a 
possible terrific hemorrhage, this advice is not too heroic. 
Wounds of the vertebral artery in this part of the neck are more 
common in the canal of the transverse processes. At the base of the 
neck the wounds of the vertebral are more grave than those of the 
carotids. 
The diagnosis of this wound will be made only when upon cutting 
down through the extra vasated blood it is found that the carotid artery 
and the jugular vein are intact. Then, when the hemorrhage is profuse, 
it should be stopped by plugging with the finger or by packing, and a 
loop ligature should be applied on the subclavian or the innominate 
before proceeding farther; when the wound in the vertebral can be located, 
it should be tied above and below; if necessary, a transverse process 
should be cut away with the bone-nippers. These remarks apply also 
to the wounds of the deep cervical, the inferior thyroid, the superior 
thyroid, the lingual, and the pharyngeal. 
Wounds dividing- the sterno-mastoid muscle may entail power of 
the muscle from lengthening due to the cicatrization. When the 
muscle has been completely severed and the head is still, it is some- 
times brusquely thrown to the severed side by the contraction of the THE LATERAL REGION OF THE NECK. 
251 
intact sterno-mastoid. In case of division of the muscle front opera- 
tion this does not take place, because the other muscles have gradually 
become accustomed by the pressure of the tumor to keep the head prop- 
erly balanced. The severed ends must be strongly and closely stitched 
with strong catgut, and the head kept in proper position by a liquid- 
glass bandage. 
Incised penetrating wounds of the internal jugular are perhaps 
more serious than the wounds of the carotid, because of the danger of 
penetration of air. When the respiration becomes embarrassed the 
hemorrhage increases, just as in tracheotomy, where as soon as the tube 
is introduced the hemorrhage ceases. These wounds are oftenest tear- 
ing wounds during the removal of tumors. 
Whatever be the cause, if the vein alone is wounded the blood is black and 
flows continuously. The first thing to do is to plug the opening to prevent the 
penetration of air; then make pressure above and below with the fingers, enlarge 
the wound, and fill it with boiled water to prevent the possible penetration of air; 
then look for the wounded vein and ligate both ends. The proximal end is the 
most dangerous, because of the entrance of air and of the abundance of blood. 
When the compressing fingers are in the way, or if their pressure is ineffectual, a 
provisional loop ligature should be placed around the internal jugular until the 
wounded ends are ligated. When the wound is low down, it may be necessary to 
resect the sternum and place a provisional ligature around the innominate vein or 
the superior cava. Incised wounds of the superior thyroid, lingual, and facial veins 
close to the internal jugular are almost as severe. 
Incised penetrating wounds of the carotids give rise to profuse, even 
terrific, hemorrhage. When the wound is large or when the hemor- 
rhage is moderate, unless at once attended to on the spot, it may be 
immediately mortal. A man will thus bleed to death in four minutes 
from the carotids, it is said. When the larynx or trachea is wounded, 
the blood penetrating in them causes death also from sulfocation. 
The hemorrhage is sometimes stopped by fainting if the wound is not too large. 
Upon reaching such a case, the first thing to do is to plug the wound with the 
fingers or pack it quickly. Packing will stop the hemorrhage only temporarily if 
the vessel is of any size above one-sixteenth of an inch. It is best and safest to 
enlarge the wound and attempt to ligate the two ends in the wound ; if this causes 
too much bleeding, a loop ligature must be applied, as above described. If the 
bleeding has stopped, it must be borne in mind that it will almost surely return, 
and that it may do so when proper surgical assistance cannot be procured, and the 
patient may bleed to death ; therefore, the case should be treated as described 
above for punctured wounds. 
Incised wounds of the nerves of the region (recurrent, phrenic, 
pneumogastric, sympathetic, spinal accessory, cervical plexus) are fol- 
lowed by the following symptoms: When the recurrent is wounded 
there is aphasia more or less complete. The section of the phrenic and 
pneumogastric on one side only is accompanied by respiratory and cir- 
culatory irregularities ; they are not necessarily fatal, but it is a most 
serious complication. 
Park has shown that only about 50 per cent, of these cases are fatal. Complete 
wounds of the sympathetic are followed by atresia of the pupil, slight ptosis, con- 
gestion of the conjunctiva, headache, congestion of the side of the face (unless 
only stimulated); it produces mydriasis, pallor of the face, protrusion of eyeball. 
Injury of the superior laryngeal nerve is sometimes very serious. When possible 
the divided ends must be sutured with fine silk. 
Rupture of the sterno-mastoid is the most common rupture of all 252 
SURGICAL DISEASES ANI) INJURIES OF THE NECK. 
the muscles ruptured; it has taken place after falls, sudden twists, 
violent muscular contractions. There are great pains, a depression on 
the course of the muscle, great hsematoma; the head is often twisted 
by the action of the other muscles. 
The treatment consists in placing the head in proper position and 
immobilizing it in a liquid-glass bandage. The rupture is usually partial; 
when complete the ends are far apart; it is well to cut down and stitch ; 
otherwise a kind of torticollis may result from the lengthening of the 
muscle. 
Hsematoma of the sterno-mastoid in the new-born is most re- 
markable and unique: it usually appears after birth; it is more fre- 
quently on the right; it occupies the body of the sterno-mastoid, par- 
tially or totally, forming a part of its substance; it is firm, elastic; it is 
oval; it is stationary. There is no pain except on pressure; the head 
is inclined as in torticollis; there is no tendency to grow nor to suppu- 
rate ; it usually disappears by resolution in a few weeks or months. 
It is thought to be due to obstetrical traumatism or to a malformation; 
it is common after breech presentation when traction has been made to 
extract the head ; it may cause a permanent torticollis. It must not be 
confounded with enlarged nodes. 
Induration of the sterno-mastoid in adults is syphilitic : it may be 
a diffused sclero-myositis; it may occupy the whole muscle, which is 
transformed into a cord, or it may be localized in one spot. 
Gummata of the sterno-mastoid are found usually at the inferior inser- 
tion of the muscle; they may attain the size of an orange. This mus- 
cle is a point of election of gummata ; they develop rapidly in four 
weeks, without traumatism and without trace of pain. One case of 
hereditary syphilis of the sterno-mastoid is reported. 
Neuroses are represented by the disease known as torticollis. 
Torticollis, also called wry-neck, is a deformity of the head and 
neck in which the face is turned upward and to one side. It is not a 
very rare disease. The causes are numerous. The pathological lesions 
vary also with the causes. There are also atrophy of the face and 
cranium of the affected side, sometimes strabismus, impairment of 
vision, dysphagia. There are usually no general symptoms. 
Acute, transient, or rheumatic torticollis is that due to cold: it presents no 
cranio-facial deformity; it may affect the sterno-mastoid, the trapezius, or all the 
muscles of one side. 
The peculiar point in the treatment is to immobilize the head in a soluble- 
glass bandage for a few days. 
Intermittent or spasmodic torticollis is characterized by a sort of convulsive to- 
and-fro motion of the head without cessation for short intervals or during sleep. 
The name is a bad one, because there is no spasm, but simply a loss of dynamic 
action—a lack of muscular synergy. The head is easily restored to its proper posi- 
tion, but it returns to the vicious one: this may become permanent. The spasms 
are limited to the sterno-mastoid, trapezius, and splenius; when the patient is 
lying down with the head flat there is no deviation; when sitting up, the head 
loses its equilibrium; it is first inclined laterally, and then in rotation; the move- 
ments are slow, gradual, without jerks. The head is easily straightened by an 
assistant, but it falls back immediately when the support is withdrawn. Electricity 
and massage are the most usual means employed, together with a collar apparatus; 
stretching or section of the spinal nerve has been done in one case with only 
temporary improvement. 
In articular or osseous torticollis due to tuberculous osteo-arthritis, suboccipital 253 
THE LATERAL REGION OF THE NECK. 
disease, cervical arthritis, and in that due to tumors, the head cannot be budged, 
from its absolute immobility on the vertebral column; the head is not twisted as 
in real torticollis. 
In torticollis by contraction the head can be straightened; the muscle retains 
its shape and its contractility: it is the trapezius that is most commonly affected. 
In torticollis by retraction the head cannot be thoroughly straightened, and 
there is the persistence of a hard-stretched muscular cord. Sometimes it requires 
the administration of an anaesthetic to determine these points, and whether it is 
the sterno-mastoid or the trapezius which is affected or the deep muscles. 
Torticollis by retraction of the sterno-mastoid is also called torticollis by con- 
traction. It is the most common: it is characterized also by a hard-stretched cord 
along the course of the sterno-mastoid, especially when the head is rotated in a 
proper manner. That it may be congenital is recognized, but it is rare; it is 
sometimes called obstetrical when it is thought to be due to the traumatism pro- 
duced by the forceps; it may be due to myositis syphilitica or to a gumma; it may 
be due to disease of the central nervous system or to the nerves of the muscle. It 
is called ocular when induced by defects of vision—i. e. headache, diplopia, 
astygmatism, amblyopia. 
The 'pathological lesions are a fibrous degeneration or transformation 
of the muscle : it usually occupies the lower two-thirds; the right side 
is more frequently affected. Cranio-facial atrophy is due to the defec- 
tive nutrition of the parts. 
The prognosis is that the deformity always tends to increase. 
The treatment consists in performing tenotomy, subcutaneously or 
openly, of the affected head or heads. The best time to operate is not 
before the third or fourth year. The disease has no influence on the 
development of the skeleton up to that age; after the tenotomy a 
proper collar apparatus, with or without suspension, must be used. 
In permanent paralytic torticollis the head is inclined to the opposite side of the 
hemiplegia, due to the action of the sterno-mastoid of the opposite side: it may in 
the course of time bring on a retraction of that muscle. No other form of par- 
alytic torticollis is recognized by most writers. The head can be straightened, 
and remains so only as long as it is supported. 
The treatment presents nothing special except to apply also a supporting 
apparatus. 
Torticollis of the platysma has been observed, also of the scaleni. Hysterical 
torticollis is diagnosed by anaesthesia. 
Inflammations in the sheath of the sterno-mastoid are common : 
sometimes they begin in one of the small lymph-nodes situated in the 
sheath itself; when originating from these, it is remarkable that the 
inflammation and the pus that usually follows it remain very strictly 
limited to the sheath, and descend toward the lower third of it, near the 
clavicular attachment, where they become superficial. This inflamma- 
tion leaves after it a stiffness and a shortening of the muscle. 
Phlebitis of the internal jugular vein is not very common ; it is 
usually due to infections from the interior cavities or to metastasis. It 
is accompanied with great pain and swelling along the course of the 
vein ; it is often complicated with phlebitis of the lateral sinus and with 
cerebral symptoms. 
It is diagnosed with the exploring needle; it is of the utmost im- 
portance to diagnose early and to evacuate early by incision or dilatation 
on a guide. 
Angeioma of the neck is sometimes called sanguineous cyst. It must 
not be confounded with a cyst in which hemorrhages have taken place 
or have opened into a cavity; it may be superficial, deep, or caver 11- 254 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
ous. Angeioma sometimes presents a single vein opening in the jugular 
by one or several orifices; sometimes several angeiomata open into the 
jugular. The neck is a special seat of ampullar venous dilatations, 
forming cavities in an erectile tissue with narrow spaces. Angeioma is 
often completely reducible. In operating it is advisable to place a liga- 
tion on the large vessels as soon as possible before extirpating the tumor, 
thereby diminishing very much the hemorrhage during the removal and 
facilitating the same. A sanguineous cyst is sometimes due to a serous 
cyst with a hemorrhage in its cavity. 
The aneurisms of the carotids are seldom traumatic; however, 
they may be the result of contusions. The common carotid is more 
frequently affected; it is comparatively frequent in females, surely 
more so than the other aneurisms; it is also more common in young 
subjects than aneurisms of other arteries. These aneurisms may be 
confounded with vascular or aneurismal goitres, pulsatile sanguineous 
cysts of the thyroid when they exist on the course of the carotids ; also 
with pulsatile encephaloids; also with other tumors of the neck situated 
on the course of the carotids. 
The determination of the affected artery in cervical aneurisms is often most 
difficult. Clinically and practically, the diagnosis is made by operating. A pro- 
visional ligature should be applied below the tumor. When this stops the pulsa- 
tions, another ligature should be placed above: if this be not possible, the ligature 
below should be tightened, the sac incised, the upper end of the artery secured, 
and the bleeding points, if any, clamped, and the sac extirpated if not too closely 
adherent to the important vessels and nerves. When, after placing the loop liga- 
ture, the pulsations are not affected, it is because the wrong artery is attacked; the 
loop should still be kept in place and the vertebral should have a loop ligature 
placed under it, when the pulsations will stop; another ligature should be placed 
above, if possible. 
The Supraclavicular Region. 
Congenital Atrophic Malformations.—A form of atrophy of the 
region is presented in subjects, young and old, in whom the supraclav- 
icular fossa is unusually deep, causing the deformity called “ salt-cellar 
neck.” Orifices of congenital branchial fistulse are sometimes met with 
in this region. 
Punctured wounds of the subclavian vein and artery may also 
give rise to serious hsematomata. When persistent they should be aspi- 
rated or incised. We should bear in mind that haematoma may be due 
to a wound of the vein, and that the connection may still exist. This 
will surely be the case if after aspiration it fills up again. In case of 
incision the deeper clots should not be disturbed, so as not to open the 
wound in the vein in case that lesion has occurred. 
Injury to the subclavian artery is recognized by the pulsations of 
the haematoma; it is then a traumatic aneurism. The artery should be 
ligated. When the swelling is moderate, the ligation should be made 
in the supraclavicular region, using, if necessary, an aneurismal needle 
with a detachable point. In the majority of cases this simple ligation 
will suffice to cure the aneurism; if not, compression of the axillary 
or its ligation should also be done; then the sac incised and the injured 
points ligated above and below. THE SUPRACLAVICULAR REGION. 
255 
When on the right side, the artery can only be reached and encircled in its 
second portion after dividing the anterior scalene; no permanent ligature should 
be applied there; a provisional loop ligature should be placed, the sac incised, and 
the injured point of the third portion ligated permanently above and below. On 
the left side the ligation of the second portion can be made permanent at once, as 
it is as safe on this side as a permanent ligature is unsafe on the second portion of 
the right side. When the swelling is so great as to cause the failure of the above 
procedure, or so as to discourage even the attempt, but only then, a provisional 
ligature should be applied upon the first portion of the subclavian; the axillary 
should be compressed or treated in the same way: then the sac is incised and the 
two ends ligated. In some cases these ends cannot be found. Packing with bits of 
aseptic sponge should then be resorted to, with compression over it. Should the 
hemorrhage return, the clavicle should be sawn through and the two ends secured. 
Incised wounds of the subclavian vein are most serious, because 
of the amount of bleeding often causing rapid death, and also because 
of the quick penetration of air into the vein. The vein should be at 
once plugged with the finger, or, better, an aseptic packing; then an 
attempt should be made to enlarge the wound and to clamp it, and then 
ligate the two ends. When this is impossible a provisional loop liga- 
ture should be applied on the first portion of the vein ; also compression 
should be made on the axilla and the two ends ligated; the ligation of 
the proximal end is to secure against hemorrhage and also entrance of 
air, but the ligature also of the distal end is of course indispensable. 
Wounds of the lymphatic duct on the right side and of the tho- 
racic duct on the left are diagnosed by the oozing of the peculiar fluid 
they contain. If possible, the distal end should be ligated, and this 
usually stops the flow, since there is a valve on the provisional end. 
There is seldom if ever any discharge from it. When ligation is impos- 
sible, compression will often suffice. It is very seldom that any further 
trouble is noticed, because there exists usually two or three branches of 
that duct, and the uninjured ones carry on the circulation. When this 
fails and a chyle fistula is established, then the patient gradually loses 
flesh and succumbs. 
Wounds of the brachial plexus are followed by paralysis of the 
affected area ; they should be sutured at once. The lesions, from what- 
ever cause, may affect only one branch. These neuroses never affect the 
internal, anterior, and posterior surfaces of the arm, because these are 
supplied by the anastomoses of the intercostal filaments with the inter- 
nal cutaneous. They must not be confounded with the anaesthesia and 
paralysis resulting from contusions of the shoulder in hysterical subjects 
(hystero-traumatism). 
The treatment is by electricity. If a callus includes a nerve, it 
must be resected. 
Incised wounds of the phrenic nerve are most serious. However, 
when the nerve has been pressed upon by a tumor for some time, the 
wounding of it is not so dangerous. 
Incised wounds of the apex of the lungs are not so apt to be fol- 
lowed by emphysema as the punctured wounds. 
Neuroses.—Sometimes the callus of a fracture of the clavicle 
includes a nerve branch ; hence neuralgia or paralysis requiring resec- 
tion of the callus. A simple contusion, without fracture, may produce a 
paralysis of the plexus. Repeated slight contusions may produce paral- 
ysis, as in the case of the strap of the carriers, especially water-carriers. 256 
SURGICAL DISEASES AND INJURIES OF THE NECK. 
The Posterior Region of the Neck. 
Wounds of the spinal canal through the interlaminar spaces when 
the head is flexed forcibly, or through a fracture of the laminae, are 
serious only if becoming infected. 
Incised wounds reaching the spinal cord itself are followed by 
paralysis of the parts below. If the wound be and remain uninfected, 
the cicatrization by primary union may take place and the paralysis 
disappear; if not, it will be permanent. If between the occipital and 
the atlas or axis the oblong medulla is severed, death is instantaneous. 
Infanticide is often produced by a long needle or pin driven between 
the occiput and the vertebra. If the lesion is above the origin of the 
phrenic, death follows quickly by paralysis of the diaphragm. 
Wounds of the posterior region are said to be followed by sexual 
impotency when the membranes of the cord are involved; also by 
paresis and wasting of the lower extremities, also of the testicle. Larrey 
contends that this may take place even when the cord is not affected. 
Ruptures of the muscles of the nucha are reported in those who 
carry heavy loads on the head. 
The symptoms are those of other muscular ruptures. 
Ruptures of the attachments of the rhomboid and of the elevator of 
the angle of the scapula have been seen in farm-laborers. 
Neuroses are represented by acute torticollis (posterior) of the 
trapezius. This is said to be even more frequent than the torticollis of 
the sterno-mastoid. When in the trapezius and complexus, the head is 
inclined on the affected side, but the chin is toward the opposite side; 
the head is slightly thrown backward. There is no cord, no diffuse indu- 
ration, no atrophy of the face : the pain is near the atlas, and is increased 
by pressure. Under anaesthesia the head can be straightened. This 
torticollis may be confounded with occipital arthritis with inclination of 
the head. 
The treatment consists in applying a soluble-glass bandage or a 
plaster apparatus; it should be worn one year. 
When both the trapezius muscles are affected the head is thrown 
back. In cases of torticollis of the trapezius the sterno-mastoid is often 
also contracted, but it is a contraction of immobilization; the pain is 
along the trapezius, and not along the sterno-mastoid. Very often the 
torticollis affects also simultaneously the deeper muscles, the splenius, 
the elevator muscles of the scapula, the rhomboid. The scalenes and 
the platysma are sometimes the site of torticollis. 
Aneurisms of the vertebral artery are not rare in this region ; 
they are usually traumatic, and are often high up. The artery should 
be ligated above and below if possible, or above or below whenever pos- 
sible, and the sac incised and immediately plugged with aseptic sponges. 
If possible, the distal bleeding end should be ligated. In case a second- 
ary hemorrhage should occur through the distal end, and be uncon- 
trollable by plugging, the ligation of the vertebral on the other side 
must be considered and weighed. CHAPTER VI. 
SURGERY OF THE CHEST. 
Frederic S. Dennis, M. D. 
Malformations . 
A congenital malformation of the thorax frequently occurs. This 
may follow a difficult parturition. The accompanying figure shows a 
congenital malformation in which the up- 
per ribs were separated from the lower 
ribs and the lung protruded in the in- 
terspace. This condition remained as a 
permanent malformation. 
There was a distinct sulcus into which the 
side of the hand could be thrust. Subse- 
quently marked contraction took place, and 
the side of the thorax became permanently 
distorted. 
Malformations of the chest may also 
occur as a result of the non-closure of 
the foramen ovale. The left side of the 
chest bulges outward and forward, and 
the hypertrophied right auricle is situated 
at a point far distant from its normal place. 
The apex-beat is situated below the mar- 
gin of the cartilages of the eighth, ninth, 
and tenth ribs. The opposite side of the 
chest is compressed, so that there is a 
marked difference in the symmetry of 
the thorax. 
Fig. 111. 
Malformations of the chest may arise in 
consequence of a chronic pneumonia. Respi- 
ration in these cases is carried on with great 
difficulty; the pulse is rapid; cyanosis of the 
face is present; a dry cough harasses the pa- 
tient; the alse nasi are dilated; and the ribs 
have a limited movement, and are forced inward instead of outward by the act of 
inspiration. This peculiar respiration causes the transverse diameter of the chest 
to become diminished instead of increased. 
Congenital malformation of chest 
(Sayre). 
Malformations of the chest occur as a result of rickets. The chief 
distinguishing feature is an alteration in the shape of the thorax, since 
there is usually a marked antero-posterior curvature, and the thorax is 
narrowed and flattened from before backward. These changes begin in 
early infancy or about the sixth to the eighth month, and may continue 
257 258 
SURGERY OF THE CHEST. 
until the third year or even beyond that time. The epiphyses of the 
ribs and cartilages become beaded and enlarged notably upon the pleural 
surface. To this condition the term rickety rosary has been given. This 
condition is the result of the effects of atmospheric pressure during the 
inspiratory act, combined with the lateral pressure induced by the 
weight of the upper extremities, and partly also by the fact that the 
ribs have lost their normal power of 
resistance. The angles of the ribs 
are less obtuse than in the normal 
chest, and the ribs are also somewhat 
shorter than usual. 
The sternum in the rachitic condi- 
tion of the thorax may project forward 
or in rare instances may be depressed. 
The forward projection causes lateral 
compression of the cavity. The spine 
is subject to certain alterations in its 
normal curves, since the great dorsal 
curve is exaggerated, giving rise to the 
condition of kyphosis. This deviation 
is eventually compensated for by a cor- 
responding exaggeration of the cervi- 
cal curve and a marked diminution in 
the lumbar convexity. As the child 
grows, lateral curvature may also be 
caused, with the concavity to the right 
side, owing to the position which the 
child assumes while carried on the 
nurse’s left arm. As the child grows 
up scoliosis is likely to follow in con- 
sequence of the vertical position which 
the patient assumes, together with the 
loss of resistance on account of the 
softened bones and ligaments. 
Rachitic kyphosis must not be mis- 
taken for Pott’s disease. In the former 
case extension of the body while the 
child is in the recumbent position 
obliterates in a large measure the cha- 
racteristic curve, whereas in tubercu- 
losis of the vertebrae the extension does 
not affect the angular curvature. 
In rachitic deformity the kyphosis 
is in the form of a curve, and not an angle, as in Pott’s disease. 
In the relief of kyphosis of the spine due to rickets some form of spinal brace 
can be employed when the child is up and about. In conjunction with rest in the 
recumbent position, good nutritious food, sea-bathing, and out-of-door exercise are 
to be employed as adjuvants, together with the use of the syrup of the iodide of 
iron and cod-liver oil. 
Deformity of the chest also occurs in consequence of lateral curvature inde- 
pendent of any disease. 
Malformations of the chest occur as a result of empyema. Under 
Fig. 112. 
Deformity of the thorax, the result of rickets 
(Gibney). MALFORMA TIONS. 
259 
these conditions the thorax may be barrel-shaped, and move up and 
down during respiration as if the cavity were formed of a single cylinder. 
The lateral expansion may be absent, and occasionally a marked bulg- 
ing may occur in unilateral empyema. 
In other cases there may be a marked sinking of the side of the chest-wall so 
that the thorax remains permanently deformed. Goodwillie mentions a case in 
which the ribs upon one side were lying upon the inner side of the ilium, and on 
the other upon the outer side. The deformity followed pleuro-pneumonia in 
youth. 
Malformations of the chest may occur as a result of traumatism 
sustained in early life. The injury is independent of a fracture, and as 
Fig. 113. 
Fig. 114. 
Malformation of chest following empyema (Sayre). 
the child grows the distortion becomes well marked. Pott’s disease 
usually results from this traumatism in a patient with tuberculous tend- 
encies. 
Malformation of the chest may occur in the form of lateral curvature 
due to empyema. The accompanying figures (113,114), kindly furnished 
by Dr. Sayre, give a typical illustration of lateral curvature. The apex- 
beat of the heart is at the junction of the sixth costal cartilage and 
sternum. The distance from the umbilicus to the left nipple is twelve 
and a half inches, and from the same point to the right nipple fifteen 
inches. The left side of the chest-wall is depressed, and the right side 
bulges with rotation of the vertebrae: the latter circumstance is note- 
worthy, being contrary to the teachings of the German authorities. 
Malformations of the chest also occur as a result of pleurisy. The pleura 
becomes adherent to the internal surface of the chest-wall, and in consequence the 
affected side is altered in shape and gives signs of arrest of development. The 260 
SURGERY OF THE CHEST. 
intercostal spaces are obliterated, while those of the opposite side become exagge- 
rated. The spinal column also is affected, as distinct lateral curvature follows. 
The form of the thorax is also altered in consequence of a paralysis 
of the serratus, rhomboideus, and latissimus dorsi muscles. The angle 
of the scapula projects from the latero-dorsal aspect of the chest like 
a wing. 
Malformation of the breast occurs to which the term earns pectinatum 
has been assigned. The deformity is difficult to overcome, but the 
treatment is considered in the chapter on Orthopaedic Surgery. 
Another deformity of the thorax is sometimes observed in a deep 
depression at the lower extremity of the sternum. The term bird’s- 
nest deformity has been applied to this malformation, on account of 
a fancied resemblance. There is no treatment which will effect a 
cure. 
We may have another deformity of the chest in consequence of 
poliomyelitis. 
Malformation of the chest may occur as a result of long-continued 
Fig. 115. 
Fig. 116. 
Malformation of the chest due to tight lacing (Goodwillie). 
and tight lacing. The chest shows marked thoracic with slight abdom- 
inal respiration. The diaphragm has been arrested in its growth and 
the respirations are peculiar in character (Fig. 115). 
Malformations of the chest may arise in consequence of certain occu- 
pations, also as a result of certain forms of exercise. MAI, FORM A TIONS. 
261 
The bicycle-rider comes to have a peculiar chest when the exercise is long 
continued in the stooping posture. The writer has seen a well-pronounced deform- 
ity of the chest in which the patient presented apparent atrophy of the muscles 
of the left side of the thorax and marked hypertrophy of the right side. For 
many years the patient has constantly exercised the right side of the chest in the 
practice of his profession as a musical conductor. The muscles upon the right 
side were so largely developed that the condition gave rise to the appearance of a 
lipoma. The scapular muscles bulged out on the right side in consequence of the 
unremitting and long-continued exercise of the arm in the constant swing of the 
baton. 
Deformity of the chest may follow in consequence of spastic paraly- 
sis. The chest loses its normal shape, and other muscles besides those 
of the thorax are involved. 
Fig. 117. 
Congenital absence of the pectoralis major muscle of right side (Richardson). 
Malformation of the chest lias been observed where an arrest of de- 
velopment in the vertebrae has occurred, and the sternum was either 
entirely absent or else imperfectly developed. The bone sometimes pos- 
sesses a cleft in the centre. The ribs have been observed, free or else 
attached to the sternum by fibrous tissue. The ribs have also been 
noticed as attached to each other in a manner similar to the lateral union 262 
SURGERY OF THE CHEST. 
of two ribs after the opening in the chest and the introduction of a 
drainage-tube for the relief of empyema. In these cases of congenital 
defect some protection should be worn in the form of a shield, in order 
to protect the important thoracic organs from injury likely to occur on 
account of their great exposure. 
Tattooing of the chest is of frequent occurrence. It is shown by 
Ellis that there is no class of people among whom tattooing is as com- 
mon as among criminals. Alborghetti reports that the proportion is 15 
per cent., and Lombroso 32 per cent., among prison inmates. Tattooing 
is almost exclusively confined to the male sex. In addition to the crimi- 
nal classes, the insane often indulge in this habit. Children are seldom 
found tattooed. Lacassagne has shown that among the non-criminal 
classes only about 1 per cent, of the cases of tattooing are found. 
Among sailors the thorax is a favorite seat for tattooing, and the ship 
under full sail is most frequently the emblem. Lombroso tells us that 
tattooing upon the back of the thorax or upon the sexual organs is 
found only among the residents of the Pacific islands, except in cases 
where this has been done during prison-life. Lacassagne regards tat- 
tooing “as the uninterrupted and successive transformation of an 
instinct.” 
Malformation of the chest, finally, has occurred in consequence of a 
congenital absence of the pectoralis major muscle (Fig. 117). Stintzing 
has collected from surgical literature thirteen cases of this nature. 
Injuries. 
Injuries of the thorax not proceeding from fractures are not serious, 
since in 225 cases of injuries of the chest due to kicks of horses, rail- 
road disasters, falls, and other accidents, there were only 5 fatal cases, 
as recorded in the Surgeon General’s reports of the late Civil War. 
The injuries of the thorax, excluding fractures, which are considered 
elsewhere, consist of contusions and wounds of every variety. Inflam- 
matory affections may also result from injuries, the peculiar features of 
which will be discussed later in this chapter. 
Contusions of the chest-wall are caused by direct violence, as a blow 
or a fall upon the chest. If the injury is not associated with a fracture 
or a dislocation, a rupture of a large vessel, or visceral lesions, the 
traumatism is not serious. The seat of the injury shows the presence 
of ecchymosis and the existence of swelling. The patient experiences 
pain, the amount of which is largely influenced by the peculiar character 
of the trauma. The swelling is due to a luematoma, which quickly 
appears, especially if the attachment of the pectoral muscle is torn from 
its insertion. 
In addition to the ordinary contusion of the chest-wall, an injury has been 
described under the name of commotio thoracica, which resembles contusion or 
laceration of brain. Sudden death may follow severe commotio thoracica and the 
autopsy fail to reveal any tangible lesion. In these cases the sudden death is due 
to shock. In commotio thoracica the pain is very severe, abdominal respiration is 
present, and a peculiar decubitus is observed, in which the patient, while lying 
upon the back, inclines at the same time toward the injured side. The fact must 
not be lost sight of that in apparently slight contusions of the chest-wall serious 
visceral lesions may occur. The pleura may be injured, the lung crushed, the pul- INJURIES. 
263 
monary air-vessels ruptured, and interstitial cervical emphysema follow. The 
pericardium and its contents may also be injured. In addition, secondary inflam- 
matory complications may ensue. 
The treatment of contusions of the chest-wall consists in the 
administration of opium, provided there be no contraindication to its 
use. This drug relieves the pain, has a controlling influence over 
inflammation, and diminishes the number of respirations. Hot fomen- 
tations are often applied with benefit during the first few days, after 
which a broad strip of adhesive plaster is placed around the thorax 
after the manner of dressing a fracture of the rib. 
In commotio thoracica the cardiac stinmlents are indicated, such as 
strychnia, digitalis, strophanthus, and nitro-glycerin, as well as alcohol 
in the form of hypodermic injections. 
In case dyspnoea is serious, artificial respiration should be employed, 
and if profound cyanosis is present, the inhalation of oxygen is indicated. 
The head should be lowered and artificial warmth applied to the sur- 
face of the body. 
The management of contusions of the thoracic viscera in connection 
with external injuries of the chest-wall requires no special treatment 
aside from that to be presently considered under Wounds of the 
Viscera. 
Wounds of the chest may be the result of a gunshot injury or a 
stab, either of which may be penetrating or non-penetrating. If the 
wound is non-penetrating, it is not usually serious; but occasionally a 
hemorrhage may occur from one of the large vessels upon the thorax, 
or the muscles be cut across so as to cause a hsematoma and gaping in 
the wound. In consequence, a large hsematoma develops under the 
skin, and the clot, if infected, may give rise to dangerous cellulitis. 
If the wound is small, the parts should be made aseptic after first rendering 
the region surgically clean. Iodoform or aristol should then be sprinkled over 
the wound in a very thin film, and a thin layer of borated cotton should be placed 
over the powder, and finally the cotton film painted over with a little styptic 
collodion. Hermetically sealing the wound, as suggested by Howard, keeps it 
aseptic, and with the chest-wall made as quiet as possible by restraining its move- 
ments with a dressing similar to that employed in fracture of the ribs, the wound 
quickly heals. If an hsematoma exists, it would be better to incise and turn out 
the clot and ligature any bleeding vessels, and disinfect and drain the cavity. If 
primary union fails, an abscess is likely to develop. This process may also ensue 
in consequence of a contusion or a tearing off of the attachment of the pectoral 
muscle, or from caries of the bones forming the chest-wall. In these abscesses 
fluctuation is not always felt, on account of the extravasation of pus by gravity. 
The treatment of abscesses resulting either from failure to obtain 
primary union in a wound or in consequence of injury or disease con- 
sists of early incision, disinfection, and the application of antiseptic 
dressings. If the bone is the cause of the suppuration or abscess, iff 
must be thoroughly scraped or removed. The principle of fixation and 
rest should be employed in the same manner as indicated in the injuries 
of the chest-wall. The possibility of septic visceral infection from 
external abscesses must not be overlooked. 
In the non-penetrating injuries of the chest-wall phlegmonous inflamma- 
tion may occasionally occur. The phlegmon takes its origin in the loose con- 
nective tissue which abounds in the muscles over the scapula and beneath the 
pectorals and in the axillary region. The progress of the inflammation is very 264 
SURGERY OF THE CHEST. 
rapid, and produces great prostration from septic intoxication. The anatomical 
arrangement of the axilla with its various compartments produces a honeycomb 
condition, so that the pus is contained in many small cavities. 
The treatment of phlegmonous inflammation in this region requires prompt 
action on the part of the surgeon and demands the most rigid antiseptic precau- 
tions. The numerous pockets must be opened, the contents allowed to escape, 
and the cavities thoroughly curetted and drained. Care must be exercised lest 
the important vessels in the axilla be injured and give rise to alarming secondary 
hemorrhage. 
Before dismissing the topic of wounds of the chest-wall the non- 
penetrating gunshot wound should be considered. 
Gunshot wounds of the thorax form about 50 per cent, of those which 
terminate fatally in battles, and about 10 per cent, of the gunshot wounds 
treated in hospitals. In the non-penetrating injury a fracture of the rib 
may occur or a wound of an important vessel or nerve. The non-pene- 
trating wound, uncomplicated by any injury of the bones or vessels, gives 
rise to no special disturbance beyond that of any wound of the chest-wall, 
and the mortality is only about 1 per cent. The respiratory movements 
of the thoracic parietes often retard the healing process, and occasionally 
it becomes necessary to restrain the chest movements by broad strips of 
rubber plaster after the manner of treating a fracture of the ribs. In 
the old bullets the ball often took a circuitous course around the chest. 
The writer once removed a bullet from the angle of the scapula that 
entered the body in front near the edge of the sternum. In the modern 
rifle or pistol bullet this deflection is never observed. The chest-wall 
may receive a contusion from a shell, in which dyspncea, pain, and col- 
lapse are present, at least as a temporary condition. In addition to the 
injury of the chest-wall the lung may receive a contusion or be com- 
pressed so as to give rise to severe symptoms of shock. Still further 
fractures of the bones forming the thoracic parietes, including the verte- 
brae, may increase the gravity of the case. 
In these complicated wounds the prognosis is nearly always fatal. 
The pleura may also be torn or lacerated, and this also adds to the seri- 
ous character of the injury. 
If the axillary or scapular vessels are wounded, the danger of a fatal 
hemorrhage is immediate. 
The treatment of non-penetrating gunshot wounds of the chest 
involves the disinfection of the wounds, the arrest of hemorrhage from 
any external vessels by the application of a ligature at the distal and 
proximal ends, and, finally, the immobilization of the chest-wall. If 
hsemothorax occur, aspiration of the pleura is indicated. If the move- 
ments of the chest are painful, opium can be given, since its action is 
to diminish the number of the respirations and thus relieve the pain. 
The drug also seems to have a controlling influence over inflammatory 
sequelae. 
Pleurisy and pneumonia are treated along the lines usually laid down in con- 
nection with these diseases independent of any injury. The absence of microbic 
infection makes the prognosis more favorable than a pneumonia caused by the 
presence of pneumococci. 
Penetrating gunshot wounds of the thorax are more serious. If the 
bullet be fired from the modern rifle or pistol, it is likely to perforate the 
chest-cavity. If the bullet injures a large vessel, the hemorrhage is INJURIES. 
265 
very profuse, and the patient dies very soon in consequence of the loss 
of blood. If a patient is not killed from hemorrhage at once in a gun- 
shot wound of the chest, the prospects are favorable. In other words, if 
the patient survives the shock a few hours, he is likely to recover, since 
no large vessel is wounded and only the secondary effects of injury to 
the viscera may be expected. 
The statistics of gunshot wounds of the chest have hitherto shown a very large 
mortality. This is due to the influence of sepsis, which in modern surgery is over- 
come. Thus in the Crimea the death-rate was between 80 and 90 per cent.; in the 
Franco-German War, about 68 per cent.; and in the Civil War, about 65 per cent. 
These figures are of interest only since the introduction of antiseptic wound-treat- 
ment has given brilliant results in perforating gunshot wounds of the chest-cavity. 
The signs and symptoms of a perforating wound of the chest are 
severe pain, violent paroxysms of coughing, and expectoration of blood. 
If the pleural sac be filled with blood, there are the additional physical 
signs of compression of the lung, with diminution of the respiratory 
movements and dulness over the pleural cavity. If, instead of blood 
in the pleural cavity, air gains admittance, the resonance is tympanitic 
and the physical signs of pneumothorax are present. A perforating 
wound of the chest is often associated with other injuries, notably wounds 
of the important vessels, lodgement of foreign bodies in the chest, lisemo- 
thorax, pneumothorax, pyothorax, injury of the spinal cord and dia- 
phragm, and even an associated abdominal injury. Hemorrhage may 
proceed from the intercostals, the mammary or axillary vessels, or from 
the large vessels situated in the thoracic cavity. 
The treatment of penetrating or perforating gunshot wounds of the 
thorax consists in the arrest of hemorrhage, the removal of foreign 
bodies, the disinfection of the wound, the withdrawal of the fluid from the 
pleural cavity, the management of the fractures involving the vertebrae, 
ribs, or sternum, attention to the injured diaphragm, and the alleviation 
of the symptoms arising from associated abdominal lesions. 
The arrest of primary hemorrhage is effected by a double ligature 
placed upon the proximal and distal ends of the artery. This method 
is applicable in the event of a wound of the branches of any of the large 
vessels upon the surface of the thorax. If the internal mammary or 
intercostals are torn, it may be necessary to cut away quickly a piece of 
the rib in order to reach the bleeding point. If the hemorrhage is not 
alarming, and there is an opening between the ribs sufficient to admit 
the finger, a small tampon attached to a string can be pushed into the 
thorax, and then draw out so as to make pressure upon the vessel against 
the inner surface of the rib. A hemorrhage from the lung-tissue itself 
can be controlled with a tampon, absolute rest, and large doses of opium. 
The differential diagnosis between an arterial and a pulmonary hemorrhage is 
that in the former the blood comes in spurts synchronous with the action of the 
heart and is bright red in color, while in the latter the blood wells up from the 
bottom of the wound and is dark blue or nearly black. 
A very ingenious method of differential diagnosis between hemorrhage from 
an intercostal artery and the lung-tissue was devised by Richter, who suggested 
introducing into the wound a visiting card rendered aseptic and rolled up in the 
form of a circular tube and bent at an angle, and if the blood flows out along the 
groove, it shows the origin of the hemorrhage is from the intercostal artery, but 
if the blood flows out of the wound under the card, the source of the bleeding is 
from the pulmonary tissue.. 266 
SURGERY OF THE CHEST. 
The removal of a foreign body should be attempted if it is within 
reach of the surgeon. A bullet or a part of the clothing or a piece of 
loose rib should be extracted in order to make the wound aseptic. The 
surgeon should not attempt any deep exploration, and should use his 
finger, rendered thoroughly aseptic, in preference to a probe. The dis- 
infection of the wound is accomplished by free irrigation of a solution 
made of sterilized water impregnated with bichloride of mercury of 
about 1 :2000 in strength. 
The withdrawal of fluid from the pleural cavity is indicated. Blood 
left in the pleural cavity under such circumstances is not likely to absorb, 
but to give rise to an empyema. The removal of the fluid prevents a 
Fig. 118. 
Gunshot wound of the chest (Medical and Surgical History of the War). 
purulent collection. If after a few days serum collects, it should be 
dealt with in the same manner. In case fractures of the bones forming 
the thorax are found as an associated injury, they should be treated as 
compound fractures occurring independent of a gunshot wound. 
Injury to the diaphragm is attended with a peculiar respiration, 
severe pain, and irregular pulse. The question of abdominal section 
must be considered, as rents in the diaphragm have been stitched and 
recovery followed. 
The associated injuries of the abdomen must be treated according to 
the rules which govern the surgeon in the management of these wounds 
independent of any chest complication. INJURIES. 
267 
Gunshot wounds of the mediastinum may occur so that scarcely 
any visceral injury is inflicted. The accompanying chromo-lithograph 
shows a case where' the anterior mediastinum was freely opened by a 
canister shot and the contents of the chest exposed to view. The patient 
recovered, and at the expiration of ten years was alive and apparently 
well. 
Injuries of the thoracic viscera include wounds of the pleura, lung, 
diaphragm, thoracic duct, the vessels, pericardium, and heart. Wounds 
of the heart and pericardium are discussed in another chapter. 
Wounds of the pleura occur in consequence of fracture of the bones 
forming the thoracic parietes; also in cases of severe contusion, in gun- 
shot and stab wounds. The injuries of the pleura complicating fracture 
of the ribs is discussed in another chapter. The pleura may be ruptured 
in violent contusions of the chest. 
Rupture of the pleura occurs in consequence of a severe blow upon 
the chest-wall or by a crush. This accident may occur without any visible 
external wound. If the visceral layer is torn, percussion reveals the pres- 
ence of localized dulness, and auscultation gives evidence of crepitation. 
Dyspnoea and cough occur, which in some rare cases are accompanied 
by bloody expectoration. Blood may escape into the pleural cavity and 
give rise to hsemothorax ; or air, in which case, pneumothorax develops. 
The air may be drawn in from the outside if an external wound exists, 
but the air escapes again at the same opening, and does not cause expec- 
toration of bloody and frothy mucus, as is always the case when the 
lung is injured. To this condition the term traumapnoea has been given. 
In some cases both conditions may exist simultaneously. A small local- 
ized rent reappears without much disturbance, but a large tear may be 
followed by a superficial gangrene of the lung, by abscess, or by a uni- 
lateral pleurisy. 
Rupture of the pleura may also occur as a result of a fracture of the rib or of 
the sternum. It may also appear in consequence of a gunshot wound or a stab 
wound. The lung may escape injury in some cases, although it is usually com- 
plicated with the injury of the pleura. If the lung is wounded as an associated 
injury, the shock is profound, the respirations are largely abdominal, and expec- 
toration of blood and frothy mucus occurs. If the wound in the chest-wall cor- 
responds to the wound in the lung, a peculiar hissing sound follows, which is 
caused by the passage of air through the wound into the lung. 
The treatment consists in the fixation of the chest-wall by strips of adhesive 
plaster; in the diminution of the respiration by the administration of opium; in 
the withdrawal of the blood from the chest by aspiration ; and, finally, in the 
judicious employment of stimulants. If a compound fracture exists, the wound 
must be rendered aseptic and the bullet and any foreign body removed if within 
reach. 
Hsemothorax and pneumocele are likely to develop in conse- 
quence of the injury of the pleura. The former occurs from rupture 
of the lung itself or of the internal mammary or the intercostal arteries, 
and the latter from hernia of the lung through the tear in the pleura. 
When this latter condition arises, the term pneumocele or hernia of the 
lung or prolapse of the lung is used. 
The pneumocele may occur at the time of the injury, or subsequently 
by pressure of the lung against a weakened cicatrix. 
Pneumocele is rather a rare sequela in penetrating wounds of the chest, since 
in 20,000 cases of chest wounds only 5 were followed by pneumocele. The most 268 
SURGERY OF THE CHEST. 
frequent seat of pneumocele in punctured and stab wounds is upon the anterior 
part of the chest. Occasionally the wound is situated low down, so as to be com- 
plicated with hernia of some of the abdominal viscera. 
If the pneumocele be primary, the parietes are injured, and the lung is forced 
out by a violent act of expiration with the glottis closed. The section of lung 
thus protruded may be returned if seen soon after the occurrence of the accident; 
if not, the hernia cannot be returned, owing to the enlargement of the mass due 
to congestion and inflammation. In very exceptional cases the pedicle may 
become more or less strangulated. The mass can now be left to slough, or it can 
be amputated by Paquelin’s cautery and the wound left to heal by granulation. 
Instead of the peritoneal sac, as in abdominal hernia, the pneumocele may be 
surrounded by the pleura, which thus forms a serous covering. 
If the pneumocele occurs secondary to an injury, the hernia does not present 
for some time. The tumor has a peculiar crackling feeling under the skin, which 
in this variety is usually intact, and auscultation reveals the presence of air in the 
pulmonary vessels. The tumor increases in size on expiration, and diminishes 
during the act of inspiration. The percussion-note is resonant and the respiratory 
murmur is intensified. The escape of the hernia may be due besides to a weakened 
cicatrix, to a rupture of the intercostal muscles, or to some degenerative changes 
in the muscular wall. The writer has under observation a case of pneumocele 
the result of a stab wound. The hernia gives rise to no unpleasant symptoms, the 
patient wearing over the tumor a small compress which prevents it from enlarging 
and protects it from injury. 
Rupture of the lung- has occurred without any external injury of 
the chest-wall. The injury is serious, and is accompanied by emphysema, 
by pneumothorax, by luemothorax, by haemoptysis, and sometimes by 
empyema. Pleuritis and pneumonitis have also followed rupture of the 
lung. Gosselin believes that at the time of the accident the lung is 
fully distended with the glottis closed, so that the lung is incapable of 
yielding and rupture of the organ occurs. 
Ashhurst collected 39 cases of rupture of the lung, excluding gunshot injuries, 
with 12 recoveries, and Otis, 25 cases with 11 recoveries. 
In cases of injury to the lung the danger is not so great from the consequences 
dependent upon the trauma of the lung itself as upon associated injury of the 
viscera. 
Hilton has described “Cases of Rupture of the Pulmonary Tissue” in which 
the air enters into one of the mediastinal cavities, notably the posterior, and then 
passes along the course of the nerves and blood-vessels into the neck and axilla. 
The air even passes downward along the sheaths of the blood-vessels until it 
reaches the lower limbs. 
Wounds of the intercostal artery are by no means trivial, since, 
according to the Surgeon General’s report of the Civil War, 11 out 
of 15 cases, or 73.4 per cent., had a fatal termination. This high rate 
of mortality is not to be wondered at, since the intercostal artery can 
pour out four pounds of blood into the pleural cavity. The vessel can 
be ligatured near the vertebral column before the artery bifurcates, 
or one of its branches can be secured after the bifurcation along the 
inner surface of the rib. The vessel is usually injured by a gunshot 
wound complicated by compound fracture of the rib. The ligation of 
both ends is necessary, and the compound fracture of the ribs dressed 
aseptically, and aspiration of the pleural cavity if that sac is tilled with 
blood. 
Many devices were employed to arrest hemorrhage from this vessel, but these 
have at the present time only an historical interest. Girard suggested enlarging the 
wound sufficiently to pass a curved needle around the rib and to the thread attach 
a compress, and draw it against the inner surface so as to compress the vessel. 
Reybard suggested a curved blunt-pointed needle which also made compression. INJURIES. 
269 
Henermann employed a staphylorrhaphy needle. Lotteri used a steel button, and 
Quessnay utilized an ivory plate for the same purpose. All of these methods are 
objectionable, because they are likely to produce suppuration in the wound and 
injure the pleura, and be followed by secondary hemorrhage. If any means is 
employed besides the ligature, an antiseptic compress is the only safe measure. 
The compress can be introduced through the wound into the chest, and the tam- 
pon drawn outward against the rib. The gauze can be used like the finger of a 
glove, and then the pocket packed and drawn against the rib. 
The internal mammary artery has been injured as a result of gun- 
shot and stab wounds. The wound of this vessel derives its chief 
importance not only from hemorrhage, but especially from associated 
injury to the pleura. This complication gives rise to hsemothorax. The 
artery has been injured by a sabre in which the point glided off from the 
sternum and perforated the intercostal space. 
Langenbeck mentioned to the writer that he had seen 5 cases of injury of this 
artery as a result of duels among the students in the University of Gottingen. Of 
this number, 2 died and 3 recovered: Langenbeck also stated that up to 1876 there 
never had been a successful ligation of the internal mammary artery. 
The surgical anatomy of this artery is important in relation to its ligation. 
The internal mammary artery comes off from the subclavian artery at a place cor- 
responding to a point between the two heads of the sterno-cleido-mastoid muscle 
and directly opposite to the thyroid axis. The vessel rises parallel with the ster- 
num one centimetre from its edge, and has the vein on its inner side between the 
artery and the edge of the sternum. In the upper two intercostal spaces the artery 
lies on the pleural sac, and if injured in this part of its course the pleural cavity 
is in all probability opened. In the intercostal spaces below the second the pleural 
cavity need not be necessarily opened, and, as a matter of fact, is not in wounds 
of the internal mammary, since the triangularis sterni muscle is between the 
pleura and the artery. It thus follows that if the artery is wounded above the 
third intercostal space, the pleural cavity is opened; if below the third interspace, 
it probably escapes injury. Tamponing the wound above the third interspace is 
therefore impossible, while this procedure can be carried out below the third inter- 
costal space on account of the triangularis sterni muscle. 
The prognosis in wounds of the internal mammary artery lias been 
most unfavorable, since Voss collected the cases and showed that the 
mortality is as high as 68 per cent. This high death-rate was largely 
due to secondary septic inflammatory processes, and in nearly all of 
these complications antiseptic surgery will relieve in the future. 
Secondary hemorrhage is responsible for many deaths after injury of 
this artery. Billroth had a case of secondary hemorrhage from a wound 
of this vessel as late as the fifteenth day, but fortunately the bleeding 
was controlled. 
Volkmann had a fatal case of secondary hemorrhage into the plenral 
cavity upon the ninth day. Palmer lost a case of secondary hemor- 
rhage as late as the fifty-fourth day. 
The diagnosis of injury of the internal mammary artery, if the lesion 
is situated above the third intercostal space, includes dyspnoea, choking, 
and hsemothorax. If below the third interspace, the respiratory symp- 
toms are absent. 
The diagnosis of injury of this artery is attended with no difficulty 
if the blood flows out toward the surface, but it is often extremely diffi- 
cult to determine this injury if the hemorrhage is internal. Under these 
circumstances rapid anaemia, the situation of the wound, and the signs 
of lung compression from blood are the points which the surgeon con- 
siders as aids to diagnosis. 270 
SURGERY OF THE CHEST. 
The treatment of injury of the internal mammary artery consists 
of ligation of the wounded vessel. If the hemorrhage is primary, the 
wound in the vessel should be found, and the artery completely divided 
and both ends ligated. If the hemorrhage is secondary, the artery 
should be exposed in the next intercostal space above the wounded point, 
and the vessel tied in its continuity. It has been necessary to resect a 
portion of the rib in order to reach a wounded vessel. 
The technique of ligation of the internal mammary consists of making an 
incision parallel with the ribs and in the centre of the intercostal space at right 
angles to the outer side of the edge of the sternum. The skin, fascia, pectoral 
muscle, and intercostal muscle are all divided and the vessel exposed. The artery 
runs one centimetre to the outer side of the sternum, and has the vein between it 
and the border of the sternum. 
Langenbeck suggested another incision parallel with the artery, and at the 
point of election of ligature made a horizontal incision at the upper termination 
of the vertical incision. This T-incision affords more room to the operator. The 
pleura must not be injured when the resected portion of the rib is lifted from 
beneath by an elevator. The edge of the rib must be made smooth, so that no ill 
consequences may follow from the sharp edges of the divided rib. The hsemo- 
tliorax must be relieved by incision below, and a drainage-tube can be introduced 
above through the original wound, now enlarged by a partial resection, and carried 
into the pleural cavity and out of the chest at the point below where the wound 
was made, to afford drainage for the blood contained in the pleural cavity. The 
pleural cavity can be irrigated through the tube, if necessary, by an antiseptic 
solution. 
Injury of the thoracic duct occurs in consequence of stab and gun- 
shot wounds, and also as a result of contusion of the thorax and fracture 
of the vertebrae and ribs. The duct has been ruptured by dilatation as 
a result of pressure of an abdominal neoplasm; also from stenosis of 
the duct the result of inflammation. If the wound has an external 
opening, a whitish fluid escapes, which upon analysis proves to be 
chyle. The fluid has been known to escape into the pleural cavity, and 
that cavity tapped upon the supposition that an empyema existed. An 
important clinical sign as to the character of the fluid is its coagulability 
upon exposure to the external air and its milky appearance if removed 
during the process of digestion. 
Wounds of the pericardium may occur as a result of fracture of 
the ribs or sternum, but they are generally produced by a stab or bullet 
wound. The injury is serious on account of the mechanical pressure 
of the blood upon the heart. 
Paracentesis pericardii should be performed if the diagnosis be cer- 
tain of hemorrhage into the sac : ice applied over the pericardium has 
been suggested in conjunction with the administration of opium, and only 
sufficient cardiac stimulants to prevent heart failure. Over-stimulation 
is of course attended by fatal results. The place to perform paracen- 
tesis pericardii is in the fifth intercostal space, just to the left of the 
sternum. 
Wounds of the heart may be caused by traumatism, as a gunshot 
or stab wound, or by perforation of a fractured rib. These wounds are 
not necessarily fatal. 
The signs of a wound of the heart are great pain, cardiac syncope, 
hemorrhage into the pericardial sac, flatness upon percussion over the 
pericardium, with an increase of the limits of the sac and diminution of 
the heart-sounds. Death may occur in consequence of mechanical pres- EMPHYSEMA. 
271 
sure upon the heart by blood in the pericardium or paralysis of the 
heart-muscles owing to injury. 
The treatment of wounds of the heart consists in preventing cere- 
bral anaemia by lowering the head; in affording relief from pain by the 
use of opium; in stimulating the patient with judgment, since over- 
stimulation is attended by quickly fatal results; and, finally, in increas- 
ing the bodily temperature by the application of artificial warmth. 
Rupture of the heart is a fatal injury. Gamgee collected 28 cases, 
in 9 of which there was no injury of the thoracic wall. In about 14 of 
the cases the pericardium was uninjured. The right ventricle was rup- 
tured by traumatism, while the left ventricle was ruptured by other 
causes. In all of the causes of rupture there was found to be fatty 
degeneration of the heart-muscles. Rupture has occurred during 
tetanus or on account of an embolus or a thrombus of the coronary 
arteries or its branches ; also by an abscess involving the muscular walls 
of the heart; or, finally, by the escape of blood from a ruptured aneur- 
ismal sac. 
In traumatism of the upper part of the vertebral column or 
in diseases or tumors of the segments of the cord itself there are pres- 
ent certain nervous manifestations which affect the thorax. These phe- 
nomena should be studied, because upon an accurate interpretation of 
them a diagnosis of the lesion and its situation can be established. They 
appear immediately in case of fracture or dislocation or foreign body, 
a short time after the injury in case of hemorrhage, and a long time 
after the beginning; of the cause in case of disease or tumor. ( Vide 
page 88.) 
In the case of disease or tumor the onset is therefore slow and grad- 
ual, while in hemorrhage it is shortly after the injury, and in fracture 
and dislocation immediately upon receipt of the traumatism. 
Emphysema. 
This condition arises in consequence of the escape of air from the pul- 
monary organs into the subjacent subcutaneous tissues. The emphysema 
may occur as a result of a wound of the lung produced by mechanical 
violence or by a stab or gunshot wound. Emphysema may occur also 
without an injury to the lung, in which case the air is sucked in through 
a valvular skin-wound from without into a wound in the pleura during 
the respiratory acts. This condition gives rise to a pneumothorax, the 
physical signs of which are the same as are ordinarily found. On the 
other hand, an emphysema may arise in consequence of a rupture of 
some air-vesicles in the lung and the pleura be uninjured. This variety 
of emphysema usually alfects the mediastinum, and then the cervical 
region, and is the result of a sudden violent compression of the chest- 
wall. 
The condition may be so extensive that the patient’s features are obliterated 
and the act of respiration seriously impaired. The writer has observed the emphy- 
sematous crackling in the scrotum from an injury to the lung. The air seldom if 
ever extravasates in the subcutaneous tissue of the scalp or in the palms of the 
hand or the soles of the feet. The air is forced along between the planes of con- 
nective tissue by the action of the muscles. Associated with emphysema is usually 
haemoptysis. 272 
SURGERY OF THE CHEST. 
Emphysema may occur as a result of sepsis, in which case the bubbles of gas 
are generated in consequence of putrefactive changes. Emphysema may also 
occur from the escape of intestinal gas as a result of a wound in the intestine. 
Emphysema may finally be caused by a valvular skin-wound, in which case 
the air is sucked into the subcutaneous tissue, and cannot escape from the opening 
on account of the closure of the valve. 
In the traumatic variety, due to an injury of the lung or pleura, the prognosis 
is not necessarily serious, since the air soon becomes absorbed. If the extravasa- 
tion is very extensive, so as to endanger the integrity of the skin or to produce 
symptoms of suffocation, incisions are indicated. This operative interference, 
however, is never to be resorted to except in extreme cases, as phlegmonous inflam- 
mation and death have followed simple incisions. If the operation is performed, 
it should be under the most rigid antiseptic precautions. 
In septic emphysema the prognosis is not so favorable, since the condition 
denotes a very intense variety of sepsis. 
The treatment consists in combating the sepsis by the application of the 
principles of antiseptic surgery. 
In intestinal emphysema the prognosis is most unfavorable, and the only treat- 
ment is an immediate laparotomy. The wounded gut should be sutured and the 
peritoneal cavity washed out under the most strict antiseptic precautions. 
Intercostal Neuralgia. 
This has been treated by surgical interference. Von Nussbaum sug- 
gested and carried into practice the operation of stretching the nerves. 
In one case he exposed by incision the eighth, ninth, and tenth intercostal 
nerves. The incision began 6 cm. from the vertebral column, and was 
carried 6 cm. through the integument, fascia, and the intercostal muscles. 
The nerve was then isolated, as it accompanies the artery and vein. In 
another case this same operator cut down upon the eighth, ninth, and 
tenth intercostal nerves upon both sides in front between the xiphoid 
cartilage and the umbilicus, and upon the outer edge of the rectus 
abdominis. In performing the operation he wounded the peritoneum 
upon the right side, but the case terminated favorably. 
The Thoracic Walls. 
The diseases of the bones and cartilages of the thoracic parietes 
include caries and necrosis, 'periostitis, osteomyelitis, also chondritis and 
perichondritis. These processes may arise in consequence of syphilis, 
tuberculosis, scurvy, and the infective fevers, notably typhoid. Any of 
these conditions may give rise to sinuses which become tortuous. 
The TREATMENT consists of opening up the sinus down to the bone, 
and, if the latter is diseased, scraping the bone as well as curetting 
the sinus itself. The track of the sinus should be packed with iodo- 
form gauze, so as to permit the wound to heal by granulation from the 
bottom. 
In addition to acute abscesses and phlegmonous inflammation, cold 
abscess is often found upon the thoracic parietes. As this variety of 
abscess is associated with tuberculosis, there is danger of a general infec- 
tion. The abscesses should be opened, irrigated, curetted, and drained. 
Injections of a solution of iodoform and glycerin are found useful, as 
well as a solution of the bichloride of mercury, after which iodoform 
powder should be dusted over the abscess and into the cavity. These 
abscesses may occur independent of any bone lesion. THE THORACIC WALLS. 
273 
It must be borne in mind that abscesses upon the thoracic wall have 
been known to perforate an intercostal space and burrow their way into 
Fig. 119. 
Erosion of sternum, the result of pressure of an aneurism (Wood Museum). 
Fig. 120. 
Erosion of vertebrae, the result of pressure of an aneurism (Wood Museum). 
the lung itself. Under these circumstances the pus is expectorated. 
In these cases there is no purulent collection in the pleural cavity, and 274 
SURGERY OF THE CHEST. 
the external abscess disappears by absorption from the surface of the 
thorax. 
Caries of the ribs or cartilages, or even periostitis, lias been known to 
give rise to a pleurisy or abscess of the lung by propagation. The 
pleuritic effusion is caused by the conveyance of germs from- the seat of 
disease through the lymph-channels direct to the pleura. The same may 
be said of inflammatory affections of the diaphragm as well as of dis- 
eases of the liver. 
The bodies of the vertebrae, as well as the sternum itself, are often eroded in 
consequence of the pressure of an aneurism. In case of perforation of the sternum 
the sac protrudes, and some of the signs are identical with those of abscess of the 
thoracic parietes. This mistake must not be made, as an incision into the sac 
upon the supposition that the tumor is an abscess would terminate in instant 
death. 
Subphrenic abscess was first described by Barlow in 1845. Hilton Fagge 
collected several cases, and, following his article, Leyden and Beck have pub- 
lished classical monographs upon the subject. Von Volkmann in 1879 demon- 
strated that purulent collections beneath the diaphragm could be treated by sur- 
gical interference. 
Subphrenic Abscess. 
Fig. 121. 
Relations of the thoracic and abdominal viscera (Beck). 
The causes of subphrenic abscess are connected -with traumatisms 
of the diaphragm, also with lesions of the stomach, notably ulcer; also 
with disturbance of the kidney, especially the left, since this organ is 
higher upon that side. SUBPHRENIC ABSCESS. 
275 
The pneumococcus h-as been demonstrated to be a common cause of sub- 
phrenic abscess. Perforation of the-caecum has likewise given rise to this variety 
of abscess, as well as perforation of the small intestine, notably the ilium. There 
are a few cases reported in which the echinococcus was the exciting cause. 
Abscesses connected with Pott’s disease when situated in the corresponding seg- 
ment of the vertebrae have given rise to this special variety. Weir reports 
cases in which the disease was secondary to appendicitis. In these cases the pus 
has forced its way upward between the liver and the diaphragm. Janeway 
reported two cases produced by carcinoma of the pylorus, and several cases have 
been collected showing the origin of the disease due to an ulcer of the duodenum. 
The signs and symptoms of subphrenic abscess vary according to 
the origin and special variety. The history of the illness leading up to 
the development of the abscess must always be considered. 
If the abscess be due to a gastric ulcer, disturbances indicative of 
that lesion have preceded its development; if to echinococcus, the his- 
tory of that disease precedes the formation of the abscess beneath the 
diaphragm; if to abscess of the kidney, examination of the urine may 
throw some light upon the diagnosis. Usually the abscess if situated 
upon the anterior surface of the kidney gives rise to swelling, pain, 
tenderness, and collateral oedema in the abdominal wall. 
If the abscess be the result of a perforation from the pleural cavity 
downward, the signs of pleuritic effusion and empyema precede the 
signs of presence of pus beneath the diaphragm (Fig. 122). The explor- 
ing needle will afford valuable infor- 
mation as to the character of the 
fluid. If it is subjected to micro- 
scopical examination, the presence 
of special germs like the pneumococ- 
cus, echinococcus, or bacillus tuber- 
culosis throws some light upon the 
etiology and diagnosis. 
Fiirbringer has called attention to 
the motions which are communicated 
to the exploring needle when intro- 
duced into the abscess-cavity as 
pathognomonic of this disease. 
Weir has called attention to the 
clinical fact that inspiration increases 
the outflow of the pus through the 
cannula in subphrenic abscess, while 
the same respiratory movement diminishes the outflow if the purulent 
collection is in the pleural cavity alone. Mayal has recently called atten- 
tion to the fact that the manometric pressure may be absent if paralysis 
of the diaphragm is present. 
The physical signs are most important. The abscess may be 
situated upon the right side, as is often the case, owing to the fact that 
subphrenic abscesses frequently develop from some disturbance con- 
nected with the intestinal canal, notably the ilio-csecal valve and the 
costal and other veins in this vicinity. 
Deep percussion elicits pulmonary resonance instead of liver dul- 
ness, and absence of the respiratory murmur from the third or fourth 
rib above downward. The line of flatness beneath the diaphragm 
Fig. 122. 
Thoracic opening- in subphrenic abscess 
(Beck). 276 
SURGERY OF THE CHEST. 
changes according to the attitude of the patient. Succussion can be 
obtained by placing the ear over the scat of the abscess, then shaking 
the patient, and the succussion note will be found to be limited to the 
subdiaphragmatic region. 
The absence of cough in connection with purulent collections in the 
region points to the subdiaphragmatic origin and seat of the fluid as 
opposed to a pleuritic origin. In some cases perforation of the lung has 
followed and the pus expectorated. In all cases of purulent collections 
in this vicinity the expectoration should be microscopically examined. 
Litten has called attention to a new diagnostic sign to which he has 
given the name of “diaphragm phenomenon.” This sign consists of a 
“shadow-like line moving across the chest down and up with exact 
inspiration and expiration.” 
Fig. 123. 
Left-sided subphrenic abscess (containing gas) (Beck). 
The treatment of subphrenic abscess consists of evacuation of the 
pus, followed by free drainage. When the diagnosis is made certain, 
free incision should be made, with resection of a portion of the rib if 
necessary. Beck suggests the space between the eighth and tenth ribs 
in the mid-axillary line. If the entrance of air into the pleural sac 
causes dangerous symptoms, the final incision can be postponed for two 
or three days. Bull in one case stitched the pleural surfaces to avoid 
infection of the pleura. General anaesthesia may be indicated, but if 
the pus be near to the surface, the abscess can be opened by the use of 
the chloride of ethyl and cocaine and the ether spray, combined with 
free alcoholic stimulation by the mouth. In regard to the irrigation of 
the abscess after incision, the same rules hold good which have been 
given in connection with Empyema. 
The Mediastinum. 
The mediastinum is the space in the median line of the body formed by the 
non-approximation of the pleurae. In front the space is bounded by the sternum. THE MEDIASTINUM. 
277 
behind by the vertebrae, and upon the sides by the pleurae. The space is divided into 
an anterior, middle, and posterior, and, with the exception of the lungs, all the 
thoracic viscera are found in this space. 
The anterior mediastinum contains the origin of the sterno-hyoid, the sterno- 
thyroid, and triangularis sterni muscles, the thymus gland, lymphatics, and the 
internal mammary artery of the left side. 
The middle mediastinum contains the pericardium with the heart, the ascend- 
ing aorta, the pulmonary arteries and veins, the superior vena cava, the bifurca- 
tion of the trachea, and the phrenic nerves. 
The posterior mediastinum contains the thoracic duct, the oesophagus, lymphat- 
ics, the pneumogastric and splanchnic nerves, the descending arch of the aorta, the 
greater and less azygos veins, and the left superior intercostal vein. 
The injuries of the mediastinum consist of contusions, wounds, 
fractures, and dislocations of the sternum. 
Contusions of the mediastinum may arise from blows and falls 
upon the chest and from crushing of the thorax. The contusion may 
be accompanied by a hsematoma which gives rise to serious cardiac dis- 
turbance. If blood collects in the space, aspiration of the cavity is 
indicated. 
The treatment for simple contusion is absolute rest by fixation of 
the thorax by means of adhesive plaster and by the administration of 
opium to allay pain and to control the movements of the chest. 
Wounds of the mediastinum follow gunshot and stab wounds, and 
are serious in proportion to the associated injuries of the viscera con- 
tained within the space. Hemorrhage is to be treated as described 
above in connection with Contusion, and the special injury of each 
viscus is to be dealt with according to rules laid down in connection 
with injury of each organ. The foreign body should be removed in all 
cases if possible, and the parts dressed antiseptically and the chest 
immobilized. Fractures and dislocations of the ribs and sternum are 
discussed in another chapter especially devoted to this subject. 
The great danger besides shock in all mediastinal injuries is that of 
abscess-formation—a condition soon to be discussed. 
Mediastinitis may be either acute or chronic. Acute mediastinitis 
takes its origin from infection, from cervical abscesses, from caries 
and necrosis of the ribs, sternum, and vertebrae, from injury such as 
gunshot and stab wounds, and also in consequence of a fracture of the 
bones forming the anterior wall of the mediastinum. Inflammation of 
the mediastinum has been observed in connection with typhoid fever, 
erysipelas, and measles, and other infectious and contagious diseases. 
The signs and symptoms consist of substernal pain, which is in- 
creased upon coughing or deep inspiration, dyspnoea, cyanosis, localized 
oedema, difficulty of deglutition, and palpitation of the heart. Fluc- 
tuation may exist, and a bulging at the episternal notch and in the cor- 
responding intercostal spaces. Percussion over the mediastinal area 
elicits dulness, changing according to the position which the patient 
assumes. Auscultation reveals the loss of respiratory murmur over 
the area of the abscess. 
Chills, rigors, elevation of temperature, rapid and irregular pulse are 
among the constitutional disturbances. 
The general constitution of the patient, the character of the suppu- 
ration, and the tendency of the pus to burrow influence the prognosis. 
The treatment of acute mediastinitis consists in affording an 278 
SURGERY OF THE CHEST. 
escape for the pus and in irrigation and drainage of the cavity. An 
incision is made over the most prominent point of bulging through the 
skin down to the abscess-wall. A trocar and cannula can now be 
inserted, and a small quantity of pus allowed to escape, the amount of 
which depends upon the condition of the pulse. Sudden withdrawal of 
all the pus at once may cause fatal syncope. The drainage-tube can be 
inserted through the cannula, and the latter withdrawn after the drain- 
age-tube is in place. If the surgeon is unable to reach the pus by 
incision, trephining of the sternum has been suggested, but it is an 
operation fraught with great danger, and is only to be resorted to in 
cases of great gravity. If by pressure of the pus necrosis of the ster- 
num has taken place, a still more serious operation is called for—viz. 
excision of the sternum. This operation, while called for to save the 
patient’s life, is nevertheless a most serious undertaking. Before cut- 
ting down upon the abscess or trephining the sternum or exsecting 
it the surgeon must be certain that he is not dealing with an an- 
eurism. 
Chronic mediastinitis may be caused by pulmonary tuberculosis or 
from scrofulosis, or be the result of primary mediastinal disease. 
The signs and symptoms are very similar to those mentioned in 
connection with the acute variety. The pain may radiate to the 
shoulder or be transmitted around the chest-wall by the intercostal 
nerves. This is likely to occur when the pus is found in the posterior 
mediastinum. The pain may be situated in front of the chest at the 
termination of the intercostal nerves, from pressure of pus on the roots 
of these nerves at their origin. 
The treatment of chronic mediastinitis consists of aspirating the 
mediastinum just as soon as the presence of pus is evident. If the pus 
is found in sufficient quantities to cause bulging of the chest-wall, 
incision can be made, using the same precautions as have been men- 
tioned in connection with acute mediastinitis. Great care should be 
exercised if the aspirator is employed, lest any air enter the mediasti- 
num, since this would rapidly convert a chronic into an acute abscess. 
The withdrawal of only a small quantity of pus at a time must be 
practised, so as to avoid a fatal collapse. The continuous drainage 
extending over a short time is the safer method. 
The Lungs. 
Before describing the surgical diseases of the lungs it is necessary to preface 
the subject by a few anatomical facts. 
The lung itself never completely fills the pleural sac, which explains the 
absence of dyspnoea in small effusions. This anatomical fact serves to explain the 
escape of pulmonary lesions in a restricted number of penetrating stab wounds of 
the chest. 
The lung itself also fails to suffer collapse in external injuries if the opposite 
lung carries on respiration and the accessory muscles are not paralyzed. Williams 
has pointed out that a sound lung soon expands when pressure of the external 
atmosphere is interrupted. 
Garland in his excellent book on Pneumo-dynamics demonstrates that the lung 
does not “swim upon an effusion, but that, by virtue of its retractility, it supports 
the entire body of the effusion, together with the diaphragm, until the weight of 
the fluid exceeds the lifting force of the lung ; that the position and shape which 
the lung assumes when associated with an effusion are determined by the balance ABSCESS OF THE LUNG. 
between the weight of the fluid and the elasticity of the lung; that the position 
and shape which the effusion assumes are determined by the varying degrees of 
retractility in different parts of the lung and by the position of the patient; that 
the excess of weight of an effusion is free to act upon the diaphragm according to 
its specific gravity; that the diaphragm does not bag down until the weight of the 
effusion exceeds the lifting force of the lung, and the same holds good for the 
obliteration of the intercostal depression ; that the heart, mediastinum, etc. are not 
pushed out of place by an effusion, whether of air or of fluid, but that those parts 
are drawn over by the opposing lung. Enormous effusions may of course increase 
the displacement.” 
The lung- may be the seat of abscess and of gangrene, to relieve 
both of which conditions surgical operations have been performed with 
success. 
Abscess of the lung may result from a pneumonia, from a suppura- 
tive inflammation, from the presence of a foreign body, or from a septic 
embolus derived from a bed-sore or a wound, or an ulcerative endocar- 
ditis ; from the uterine sinuses ; from an otitis media ; from tuberculosis ; 
or from a fractured rib or sternum. Abscess of the lung may be also 
caused by an osteomyelitis of the bones forming the thorax, by a pene- 
trating gunshot wound, by an empyema, or by ulcerating mediastinal 
nodes; likewise by traumatism and by pyaemia. It may also be caused 
by syphilis, by bronchiectasis, by extension of an hepatic abscess, by an 
inhalation or deglutition pneumonia, by puerperal fever, and finally by 
necrosis of rib, sternum, or vertebrae. 
The signs and symptoms of abscess of the lung consist of a limited 
unnatural area of dulness, changes in the respiratory murmur, increase 
in the fremitus, and vocal resonance and bronchial whisper. 
The sputum is most offensive, and the pus is greenish or brown in 
color. Shreds of lining tissue are found under the microscope; also 
crystals of fat and haematoidin and elastic fibres. Septic micrococci 
are found in the discharge, and the absence of the bacilli tuberculosis 
excludes the probability, though not the possibility, of tuberculosis. 
The presence of pus in the lung gives rise to constitutional disturb- 
ance, such as is found in connection with the formation of pus in other 
parts of the body. 
The treatment of abscess of the lung consists in the evacuation 
of the pus, to which operation the term pneumotomy has been given. 
Before operating the diagnosis should be made certain and the 
extent of the abscess mapped out upon the side of the chest. The 
kidney, liver, and heart should be carefully examined before attempting 
pneumotomy, and the cavity localized by means of percussion and aus- 
cultation and by the use of the exploring needle. There is a diversity 
of opinion as to the special anesthetic to be employed. Some recom- 
mend chloroform, because the tendency to coughing and vomiting are 
less. Others prefer ether, notwithstanding these disadvantages, because 
of its stimulant effect upon the heart. Still, again, others prefer nitrous 
oxide, since it is the safer of the two anaesthetics. The use of the A. C. 
E. mixture has also been recommended. Whatever anaesthetic is selected, 
the cardiac stimulant and oxygen should be at hand, and the hypodermic 
needles charged so as to permit of no delay in case an emergency arises. 
The battery should be in readiness in order to ensure the safety of 
the anaesthetic in such a case, as in all other capital operations. 280 
SURGERY OF THE CHEST. 
Having rendered the field of operation thoroughly sterile, an incision 
is made down to the intercostal space, and then an aspirating needle is 
introduced into the abscess-cavity. If adhesions of the pleura to the 
chest-wall are present, the operation can be completed at one time. 
The needle acts as a guide to the surgeon as he cuts into the cavity 
of the abscess. The incision into the lung can best be made by the 
actual cautery knife, but very great care must be exercised in the use 
of Paquelin’s cautery if ether is employed. A serious explosion lias 
followed the use of the actual cautery in thoracic surgery; and this fact 
must be borne in mind. 
If the cavity is reached, the pus will flow out through the cannula 
or through the open wound. The abscess-cavity cannot be irrigated 
except with very great gentleness, lest the limiting abscess-membrane 
wall will be ruptured and the fluid be let free to set up a purulent bron- 
chitis. A drainage-tube should be inserted and left in situ as long as 
pus is discharged. 
If the cavity is situated unfavorably for drainage, a counter-opening 
should be made, provided pleuritic adhesions are present. 
If after cutting down through the intercostal space no adhesions of 
the pleura are found, it is best to terminate the operation at this stage 
and defer its completion until adhesions have formed. 
With a view to assisting nature in forming adhesions, Godlee has suggested 
stitching the lung to the chest-wall, and after waiting a few days finish the opera- 
tion by cutting into the abscess-cavity. Stitching the lung to the chest-wall is 
attended with some difficulty, owing to the friability of the pulmonary tissue and 
the constant movement of the lung on account of respiration, and also owing to 
the small opening through which the surgeon is obliged to work. Even when this 
step in the operation is successfully accomplished, the stitches often tear after a 
few hours in spite of every precaution which has been taken. The opening of the 
abscess-cavity is made in the manner already described. The adhesion of the 
pleura to the chest-wall is necessary before the abscess is opened, and if nature has 
not already accomplished this, the surgeon must wait a few days in order to pre- 
vent the escape of even a few drops of pus into the pleural cavity and thus set up 
an empyema. 
The remits of pneumotomy for abscess of the lung are most encour- 
aging, since there have been 15 cases of complete recovery which the 
writer collected in two years, and to this number it is safe to say that 
several have been added. This is a most remarkable showing for a new 
operation designed to relieve a class of cases which hitherto were almost 
uniformly fatal. 
Tuberculous abscesses of the lung have also been subjected to 
pneumotomy. These abscesses can be curetted and drained if there is a 
fistulous opening leading to the cavity or, if the pain is very severe, in 
those cases in which pleuritic adhesions have formed. It is impossible 
to cut away enough adjacent pulmonary tissue to remove all the tissue 
containing bacilli tuberculosis; but fortunately it does not seem always 
necessary, since the same principle holds good here as in joint tubercu- 
losis. In the latter cases statistics have shown that in resection of a 
tuberculous joint, even if some infected tissue is left behind, nature will 
arrest the disease if aided by surgical interference. 
Gangrene of the lung may be due to traumatism such as a gunshot 
or stab wound ; from contusion of the chest-wall; from the presence of 
a foreign body in the bronchus; from an infective embolus ; from a THE LUNGS. 
281 
tuberculous abscess ; from bronchiectasis ; from a pneumonia ; and in rare 
cases from diabetes and bulbar paralysis. This condition may also fol- 
low acute interstitial nephritis consecutive to scarlet fever. Gangrene of 
the lung may also be caused by extension of suppurative processes in 
the lung, pleura, or diaphragm, or from Pott’s disease or infection from 
bronchial nodes, and, finally, from pertussis. It is seldom if ever a 
primary disease, but generally secondary to some inflammatory lesion 
of the lung. 
Gangrene of the lung may be diffuse, in which case it is usually 
embolic, or it may be circumscribed. The diffuse variety does not con- 
cern the surgeon, but in the circumscribed form operative interference 
can be undertaken. The localized gangrene may vary in size from a 
bean to that of an infant’s fist, and it is usually situated upon the periph- 
Fig. 124. 
Hydatid cyst of the lung (Riedinger) 
ery of the lung, and generally in the lower lobe. In the mass the bac- 
teria of suppuration are always found. 
The signs and SYMPTOMS of gangrene of the lung consist of cough, 
pain, rapid respiration, with expectoration of a sputum containing pus 
and necrotic shreds of lung-tissue. The odor from the breath is most 
offensive. If the sputum is allowed to stand in a glass vessel, three dis- 
tinct strata are formed. The upper is opaque and frothy and yellow in 
color, the middle layer is serous, and the lower stratum is green or brown 
in color. This latter contains necrotic pulmonary tissue with bacteria, 
crystals of triple phosphates and fatty acids, fat-globules, and pus-cor- 
puscles. Traube has demonstrated that the presence of elastic fibres is 
characteristic of lung-abscess, together with chills, elevation of tempe- 
rature, and frequent pulse. 282 
SURGERY OF THE CHEST. 
The physical signs reveal the presence of a gangrenous area : in 
some cases the signs are those indicating a cavity. 
Fetid bronchitis may be mistaken for gangrene of the lung, but the 
microscopical examination fails to show the presence of lung-tissue. 
The treatment of gangrene of the lung- is by pneumotomy, the 
technique of which is to be carried out practically in the same manner 
as has already been described in connection with abscess of the lung. 
Hydatid cysts may be found in the lung. In 2137 eases of echino- 
coccus which have been collected from various reports, 212, or 10 per 
cent., of the cases affected the lungs. 
The hydatid cyst in the lung is usually small, and no symptoms of 
importance are present to establish an accurate diagnosis. If the cyst 
is large, the signs of intrathoracic pressure are present, and this condi- 
tion is likely to be mistaken for collection of fluid in the pleural cavity 
or tuberculosis of the lung. The withdrawal of a few drops of the fluid 
from the cyst for the purpose of microscopical examination should not 
be omitted, since the presence of hooklets in the fluid establishes the 
diagnosis. 
The surgical treatment of hydatid cyst involving the lung is 
called for, since 75 per cent, of the cases terminate fatally. The cyst 
can be tapped with a trocar and cannula and a few cases of cure have 
been reported from this simple operation. On the other hand, sudden 
withdrawal of the fluid has been followed by fatal collapse. If a simple 
tapping fails to relieve the condition and the fluid becomes purulent, 
pneumotomy is indicated. 
Hydrothorax, Hemothorax, and Pyothorax. 
These are conditions which often call for surgical interference. As 
the technique of the operations for relief is practically the same for all 
these conditions, one description will suffice. 
The surgical treatment of these affections varies according to 
the peculiar character of the fluid, and consists of thoracentesis, thora- 
cotomy, and thoracoplasty. 
Thoracentesis is an operation by which fluid is withdrawn from the 
pleural cavity by the introduction of an aspirating needle, a trocar, and 
a cannula, or by a special instrument known as an aspirator attached to 
the needle. This operation is to be preferred when the fluid is not 
purulent, and when the object to be obtained is simply the relief of 
mechanical pressure upon the lungs. 
This operation may also be indicated as a diagnostic test, as the cha- 
racter of the fluid can be quickly determined after its withdrawal. The 
signs and symptoms of effusion into the pleural cavity must necessarily 
depend upon the character of the fluid. 
Acute hydrothorax is attended by a serous exudation, and is due to 
an acute pleurisy with effusion, or it may be secondary to changes in the 
circulation in consequence of heart or kidney disease. In the latter case 
it is a simple exudation, and occurs usually as a bilateral affection. 
The physical signs of fluid in the pleural cavity are—bulging or 
obliteration of the intercostal spaces, partial fixation of the thorax upon 
the affected side, and diminution of the expansion of the chest-wall, 283 
HYDROTHORAX, HEMOTHORAX, AND PYOTHORAX. 
(lulness or flatness over the affected area according to the position of the 
patient, with a tympanitic resonance just above the upper limit of the 
fluid, as pointed out by Skoda. 
Upon auscultation the respiratory murmur is diminished and a tubular quality 
is given to the breath-sounds, and to the voice-sounds a bleating character; dimi- 
nution or loss of vocal fremitus, displacement of the apex-beat of the heart, and 
displacement downward of the abdominal viscera in large effusions. In addition 
to these signs, if the fluid is purulent, there is a septic curve to the temperature, 
with chills and night-sweats and more or less cachexia. If the purulent fluid has 
existed for some time, there are signs denoting retraction and compression of the 
lung of the affected side, with alteration in the shape of the thorax, to which 
attention has already been directed at the beginning of the chapter. 
Thoracentesis is indicated when the fluid in the pleural cavity is 
sufficient in quantity to produce marked dyspnoea, or when a large 
quantity still remains, even though medical treatment has been carried 
out for a long period of time. A most important point to be considered 
in performing thoracentesis is the danger of converting a simple serous 
effusion into a purulent one, thus producing an empyema. To avoid 
this danger the most rigid asepsis must be employed in the performance 
of the simple operation. 
Thoracentesis should be employed as soon as possible after the fluid is sufficient 
in bulk to cause dyspnoea, since the lung is more likely to expand and the cliest- 
wall to contract, and the relations between the lung, pleura, and chest-wall be- 
come normal, under the circumstances of an early tapping. Permanent adhesions 
of the pleura are also prevented by an early operation. In children this is espe- 
cially important, and often will effect a permanent cure, because in this class of 
cases the fluid is due to the presence of the pneumococcus, while in adults the 
fluid usually contains, besides the pneumococcus, several other varieties of pyogenic 
organisms. 
In children no irrigation is necessary, but in adults, if the bacilli 
tuberculosis are present, with no bacteria or mixed infection, thoracen- 
tesis alone is indicated. A small amount of the fluid can be withdrawn 
by a hypodermic needle and examined, and if found to contain pneu- 
mococci only in children, or the bacilli tuberculosis only in adults, thora- 
centesis alone is indicated. 
If irrigation of the chest is to be performed, the solution should be 
warm, as cold irrigation chills the pleura and severe shock is apt to fol- 
low. In a few cases hemiplegia has followed irrigation by cold solutions. 
This accident has been ascribed to an embolus detached from a venous 
thrombus—a theory which has been proved incorrect, since in the autop- 
sies no embolus has been found. Another theory is that the hemiplegia 
is reflex in character, and is caused by some inhibitory action of one- 
half of the cerebrum. This theory has not been accepted, since the 
pleural surfaces are insensitive, because they are transformed into the 
walls of an abscess-cavity. Still another theory has been advanced, that 
the hemiplegia is epileptiform or uraemic or toxic in character or caused 
by the absorption of the antiseptic solution. All of these theories have 
been abandoned, and in their place the theory substituted that shock 
itself, in the majority of cases, is the cause of the hemiplegia. There 
are evidently other factors to be considered before we can explain every 
case of hemiplegia after irrigation with cold solutions. 
Broadbent refers to a case in which aspiration was followed by death from 
cardiac syncope in three or four hours after the tapping. The writer has seen the 284 
SURGERY OF THE CIIEST. 
same accident occur in a case of aspiration in which the fluid was caused by cancer 
of the pleura. Gayley reports a case of convulsions followed by sudden death 
after washing out the chest with a warm solution of iodine and water. Death has 
followed simple aspiration in the Buffalo clinic. Vallin met with the same acci- 
dent, and Raynaud lost a patient as the result of irrigation of the chest, death 
being preceded by convulsions and hemiplegia. 
These cases clearly demonstrate the danger of deferring paracentesis until the 
chest is full of fluid, which causes the formation of thrombi in the pulmonary 
veins. They also reveal the danger of washing out the chest after aspiration. 
Early tapping before the lung is compressed and the heart is displaced, and the 
thoracic circulation is interfered with, offers to the patient the best prospects of 
cure. 
It is a noteworthy clinical fact that the dangerous symptoms have always 
occurred during the injection of the fluid, and not during its removal. 
Before performing thoracentesis the field of operation and the instru- 
ments should be made thoroughly aseptic. This is of the greatest 
importance, in order to avoid the danger of converting a simple serous 
effusion into a purulent one. The skin over the chest and the axilla 
should be shaved, washed and scrubbed, and disinfected with a solution 
of bichloride of mercury or carbolic acid. The instruments, including 
the needle and tubing, should be boiled and then immersed in an anti- 
septic solution. The aspirator should also be disinfected. A sterilized 
rubber cloth should be placed over the chest-wall, and over the rubber, 
dry sterilized or wet bichloride towels placed. Wet towels should never 
be placed in direct contact with the chest-wall, since an acute pleurisy 
is often aggravated by this proceeding, and in cases where operations 
are performed upon the chest for other reasons a pleurisy might be 
developed. The surgeon and assistants should thoroughly disinfect 
their hands in order to ensure a typical aseptic operation. The place 
where the needle is to be introduced should be sprayed with ether or 
preferably with the chloride of ethyl, for thus the introduction of the 
needle is rendered painless. (Vide also p. 262, Yol. I.) 
Cardiac syncope should be anticipated and prevented by the use of 
stimulants before and during the operation. The patient can sit in the 
half-upright position and be supported by pillows, and these can be 
removed and the patient lowered as the fluid is withdrawn. The 
recumbent position can be assumed at once if there is any tendency 
toward syncope. The entrance of air must be prevented, and care must 
be exercised lest the viscera be injured. The fluid should be withdrawn 
slowly and only in part, as a sudden withdrawal of the fluid or of the 
entire amount at one time might be attended by dangerous symptoms 
and even by death itself. The too precipitate withdrawal of the fluid 
affects the heart, and the sudden expansion of the compressed lung 
causes great pain and distress. Coughing or a sudden change in the 
character of the pidse is an indication to arrest the flow of the fluid, 
since either of these signs points to a too rapid expansion of the lung 
and a too violent tearing up of adhesions. The parts should be allowed 
to gradually accommodate themselves to the vacuum caused by the 
removal of the fluid. It must be borne in mind that the fluid is not 
forced out of the chest-cavity as pus is from an abscess-cavity, but by 
re-expansion of the lung and by the ascent of the diaphragm. 
The point of election for the introduction of the aspirating needle or 
the trocar and cannula is either the eighth intercostal space near the IIYUR0THORAX, HEMOTHORAX, AND PYOTHORAX. 
285 
angle of the scapula, or the sixth intercostal space in the mid-axillary 
line just in front of the border of the latissimus dorsi muscle, or else at 
a point where the bulging is the most prominent or the dulness most 
marked. A small incision can be made in the skin before introducing 
the needle. The skin is now drawn up so as to form a valve-like open- 
ing, and the needle is pushed into the pleural cavity just above the 
upper border of the lower rib of the elected intercostal space. The 
free end of the tube, which is attached to a Dieulafoy, to a Potain, or 
to an ordinary aspirator, or even to Bowditch’s suction trocar and needle, 
should be immersed in a vessel containing an antiseptic solution and 
placed upon the floor at the foot of the bed. The escape of the fluid 
from the chest into a vessel containing an antiseptic fluid prevents the 
danger of entrance of air into the chest. If the flow of the fluid is 
suddenly arrested, it is doubtless due to a plug of fibrin or lymph or 
caseous pus in the lumen of the needle. The obstruction can be 
removed by introducing a stilet rendered aseptic, or by attaching the 
end of the tube to an irrigator and forcing back cautiously a stream of 
antiseptic solution into the chest. The amount of fluid to be taken 
away at one tapping depends upon the character of the fluid and the 
condition of the patient. If a large amount is present, only half should 
be removed, and that very slowly. The surgeon should constantly 
watch the patient’s pulse and respiration, and suddenly check the flow 
in case any change occurs. If the pulse becomes feeble, in addition to 
arresting the flow of fluid from the chest stimulants should be promptly 
administered and the patient placed in the supine position at once. 
After tapping the patient should be kept perfectly quiet, and the punctur&d 
wound hermetically sealed by styptic collodion painted over a thin film of aseptic 
cotton. The operation may be repeated after a short time if the fluid has accu- 
mulated in any great quantity. If the serous discharge becomes purulent, free 
incision and drainage are indicated in the manner to be presently described. The 
fluid withdrawn by tapping should be preserved for microscopical and chemical 
examination. If the fluid is clear and straw-colored, the case is probably one of 
hvdrothorax. This opinion is strengthened by the fact that the fluid contains 
albumen, a few red and white corpuscles, and epithelial cells. The specific gravity 
should be about 1010 if the fluid is a simple exudation, and 1020 if an inflam- 
matory effusion. If the fluid is bloody, this fact points to the probable existence 
of carcinoma or of tuberculosis. The presence of cancer-cells in the bloody effu- 
sion confirms the suspicion of carcinoma, and the presence of bacilli tuberculosis 
of that of phthisis, and the appearance of hooklets of the existence of hydatid 
cvsts. 
In cases of pleuritic effusion associated with tuberculosis of the lung 
the theory has been advanced recently that the fluid should not be with- 
drawn, for the reason that the pressure of the fluid compresses the lung 
and prevents it from moving. This action of the fluid is compared to 
the action of a splint on a tuberculous joint. Le Fevre reports four 
cases in which thoracentesis was followed by general tuberculosis. This 
careful observer believes that an intercurrent attack of pleurisy may be 
non-tubercular, although tuberculosis of the lung is present, and that 
an attack of acute pleurisy may be the first intimation of pulmonary 
tuberculosis. The writer has recently seen a case of tubercular 
empyema in which early tapping and irrigation were not performed. 
The autopsy, a year later, showed solitary tubercle in the right auricle 
of the heart, also a tubercle the size of a walnut in the left hemisphere-, 286 
SURGERY OF TIIE CHEST. 
which caused Jacksonian epilepsy and occasionally attacks of aphasia; 
also a tubercular osteitis of the spine and a pachymeningitis with a 
caseous deposit which caused girdle pains. Early operation might have 
prevented general infection in this case, and, judging from a surgical 
point of view in a number of cases, the writer recommends tapping and 
irrigation and drainage in tubercular empyema. 
The fact must be borne in mind that effusion in tuberculosis may be 
serous in character, similar to that found in acute pleurisy. Chemical 
analysis will show the presence of chyle in case the thoracic duct is 
wounded. 
Bacteriological examination is of the gravest importance. Search 
should be made for the pneumococci, the bacilli tuberculosis, and strep- 
tococci. 
The prognosis is more favorable when the effusion is caused by the 
pneumococcus, and next by the streptococcus, and least of all by the 
bacilli tuberculosis. 
Bloody fluid in the pleural cavity points to tuberculosis, but if that 
condition can be eliminated primary carcinoma of the pleura or lung is 
in all probability present. It must be borne in mind, however, that a 
clear serous fluid does not absolutely preclude the presence of a tumor. 
The rapid recurrence of bloody fluid after aspiration is a strong argu- 
ment in favor of cancer of the lung or pleura, or both. 
Prune-juice expectoration is a sign of cancer or sarcoma of the lung 
or pleura or lobar pneumonia. The color is due to a decomposition of 
the blood and its mixture with frothy mucus. It may also be occasion- 
ally observed in tuberculous hemorrhages. It is thus evident that while 
this peculiar sputum may occur in tumor of the lung, it also is present 
in other diseases of the lung. It is therefore not pathognomonic of tumor, 
but only one sign that is often present. The expectoration in tumor 
may be purulent or hemorrhagic, or even gangrenous, in character. 
Some writers have called attention to metastatic deposits in the 
lymph-nodes as a diagnostic aid. Behier believed that involvement of 
supraclavicular nodes is associated with tumor of the lung or pleura, 
whereas involvement of the submaxillary nodes pointed to tuberculosis 
of the lungs. 
Dyspnoea is a sign of tumor of the lung or pleura, and when these 
attacks came on very frequently and there are no physical signs present 
to explain the condition, tumor should be suspected. In these cases 
aspiration of the chest is not followed by relief as in other conditions, 
since the neoplasm itself causes the dyspnoea and not the fluid alone, 
and it is but slightly and only temporarily relieved by the withdrawal of 
fluid from the pleural cavity. 
Thoracotomy. 
Thoracotomy consists in making a free incision into the chest-wall 
in order to allow fluid to escape, and afterward to irrigate the pleural 
cavity if necessary. It often happens that nature anticipates the sur- 
geon and a spontaneous opening occurs, generally in the third intercostal 
space a few inches distant from the bone of the sternum. If an exami- 
nation of the fluid withdrawn by a hypodermic needle shows the pres- THORACOTOMY. 
287 
ence of the bacteria of suppuration, a thoracotomy is indicated. Every 
antiseptic precaution should be taken, as described under the preparation 
for thoracentesis. Local anaesthesia is usually sufficient to ensure a 
painless incision; the use of the ether atomizer or the chloride of ethyl 
or cocaine will render the operation painless. Stimulants should be also 
given according to the directions detailed under Thoracentesis. In 
exceptional cases general anaesthesia is necessary if a portion of a rib is 
to be exsected, but great care must be exercised in the administration 
of the anaesthetic. 
The place of election for the incision is in the sixth or eighth inter- 
costal space upon the side of the chest, just anterior to the border of the 
latissimus dorsi muscle. A point corresponding to the ninth rib and a 
little external to the angle of the scapula has been suggested by Godlee, 
while the intercostal space a little posterior to the scapular line, in order 
to avoid wounding the diaphragm, has been recommended by Hewson. 
Stokes believes that even the eighth intercostal space is too low. It is 
not necessary to select the lowest part of the cavity, since the diaphragm 
ascends during the escape of the fluid from the chest. 
The technique of the operation is as follows: The skin should be 
drawn upward, and an incision two inches in length should be made 
along the space between the ribs. Retraction of the skin thus affords a 
valve-like opening. Before the pleura is incised the exploring needle 
can be introduced if it has not been done before the operation. If pus 
is found, the pleura can be incised to correspond with the external 
incision. If the pus is fetid and contains many clots, the pleural cavity 
can be irrigated with a warm bichloride solution, 1 :10,000, and followed 
immediately bv irrigation with warm distilled or sterilized salt solution. 
Washing out the chest must be undertaken with caution, since cases of 
sudden death have occurred during the irrigation, to which reference has 
already been made. While washing out the chest the position of the 
patient should be changed so as to permit the antiseptic fluid to come in 
contact with all the pleural surface. A rubber drainage-tube with no 
lateral openings can be introduced, or a silver cannula with a broad 
flange, either of which must be held in place by some mechanical device. 
The chest can be irrigated daily according to the temperature. The lung 
is not apt to expand too rapidly in cases where free incision is made, 
because atmospheric pressure exists upon both sides. 
Beck recommends a resection of a portion of the rib in order to permit the 
surgeon to introduce his finger with a view to exploration of the pleural cavity and 
to remove any fibrinous exudation, and also to determine the size of the cavity. 
After the thoracotomy is completed and the irrigation finished, antiseptic gauze 
should be applied to the chest-wall and to the mouth of the tube, and over all 
absorbent cotton. A bandage can now be applied and the dressing changed 
according to the amount of discharge. The tube should remain until the pus 
ceases to flow and the discharge becomes serous in character. The wound must 
not be closed too soon, as this procedure might call for a repetition of the tho- 
racotomy. If the empyema is tubercular, thoracotomy is to be preferred to simple 
thoracentesis, since the latter permits too rapid expansion of the lung, which act 
causes tearing up of adhesions and at the same time produces paroxysms of cough- 
ing. A pneumothorax or a haemothorax might thus be engrafted upon a tubercular 
empyema. Thoracentesis, on the other hand, is recommended in children and in 
adults when the empyema is not tuberculous. Cauterization of the pleural cavity 
with a 50 per cent, solution of chloride of zinc has been recommended by Roswell 
Park. 288 
SURGERY OF THE CHEST. 
In tubercular empyema thoracotomy permits the entrance of a cer- 
tain amount of air from outside, which prevents too rapid expansion of 
the lung. If the effusion is large, the heart is displaced, and its return 
to its normal position must not be too sudden, as this might seriously 
embarrass its action. In children after thoracentesis or thoracotomy 
pulmonary gymnastics should be practised during convalescence. This 
can be accomplished by two large Woulff’s bottles, one of which is filled 
with water, while the other is empty. Children are expected to blow 
the fluid from one bottle into the other, and by this act cause a slow and 
steady re-expansion of the lung. 
In adults, occasionally, these pulmonary gymnastics may be of service. 
Empyema may occasionally attack both pleural cavities. Garr 
reports a case of this kind in which he resected a portion of the rib and 
drained the cavity on one side for four days, then made the same opera- 
tion upon the other side. 
In studying the literature of the subject the writer has collected 10 cases of 
double empyema, with recovery in every case but 1. Aspiration was performed 
in 4 out of the 10 cases, and drainage with resection of the rib in the remaining 6. 
The operation of thoracotomy, with resection of a small portion of 
the ribs and drainage, seems to be preferable to paracentesis if the lungs 
are compressed, since the admission of air from without prevents a too 
sudden expansion of the compressed lung. 
Gould has wisely suggested that in cases of double empyema, in which delay 
between the two operations seems dangerous, “ the two empyemata should be care- 
fully aspirated a few hours before the operation. By this means the shock pro- 
duced by the sudden removal of pressure from the lungs is obviated, and the 
simultaneous drainage of the two pleurae is robbed of its chief danger.” 
Cantley suggests aspiration on both sides as a preparatory procedure in order 
to diminish the amount of the fluid and relieve the heart, and upon the following 
day to perform thoracotomy on the left side, and in a few days to a week later to 
operate on the right side. He also prefers local anaesthesia to general. 
Thoracoplasty. 
Thoracoplasty, or resection of the ribs, was first suggested by Dr. 
Warren Stone of New Orleans, La, To Estlander is due the credit of 
establishing the operation as a recognized procedure. The operation is 
a serious one, and is only undertaken to save life. The mortality 
depends upon the character of the empyema and the general condition 
of the patient. This operation is indicated when thoracentesis and 
thoracotomy have failed in their object, or when a new sacculated 
empyema has developed, ora rupture in the chest-wall has occurred and 
an incurable fistula exists. The operation is also indicated when general 
tuberculosis is threatened, or when the remote effects of the empyema 
upon the brain, kidney, or lung are serious. All of these conditions 
preclude the possibility of recovery, because the lung is fixed, which 
prevents its expansion. The pleura is adherent and inelastic ; the chest- 
wall is rigid, leaving an unnatural cavity. Thoracoplasty aims to relieve 
these morbid conditions. Anaesthesia is necessary, and the administra- 
tion must be conducted with great care. The patient must not be placed 
too much on the sound side, since the narcosis might cause too much 
shock or the pus might get into the bronchi of the sound lung and cause THOR A COPLASTY. 
289 
a limited suppurative pneumonia. The number of the ribs to be exsected 
depends upon the size of the cavity, which can be explored by the linger 
before the ribs are removed. The dimensions of the cavity influence 
the size of the flap and the direction of the 
incision and the amount of bone to be sac- 
rificed. The second to the seventh ribs are 
usually selected, since they generally corre- 
spond to the anatomical situation of the 
cavity. The first rib is never selected, 
owing to its anatomical relations with the 
subclavian vessels. As much bone must be 
removed as covers the size of the abscess- 
cavity, and this may vary from one inch to 
an area extending over the entire osseous 
structure covering the cavity. A flap 
shaped like the letter U can be made, with 
its pedicle upward, as suggested by Godlee; 
or transverse cuts along the centre of each 
intercostal space, with removal of the upper 
and lower ribs in the wound, as recom- 
mended by Estlander; or several small 
flaps, as advised by Jacobson ; or a vertical 
incision, as practised by Gould. Whatever 
incision or variety of flap is adopted, the 
periosteum and ribs are removed as soon as 
the parts are exposed. 
The thickened pleura must be cut away 
and the hemorrhage at once arrested by 
forceps and ligature. 
Schede has suggested the resection of all the 
tissues of the wall except the skin and superficial fascia of the pleura, which are 
then sewed to the pleura. 
Tillmann suggests the application of the curette to the pleura after the resection 
of the ribs. Warm sterilized water should be used, following the antiseptic solu- 
Fig. 125. 
Result of Estlander’s operation for 
chronic empyema (Richardson). 
Fig. 126. 
Calcification of the pleura. 
tion, to prevent any toxic effects. The flap should be sutured, leaving in a drainage- 
tube. As the operation often lasts for some time and the condition of the patient 
is usually feeble, stimulants must be in readiness to use as required. The dis- 290 
SURGERY OF THE CHEST. 
charges must be kept aseptic, since a fresh attack might follow in consequence of 
a new infection. As long as even the smallest fistula exists the danger of new 
infection must be borne in mind. 
Thoracoplasty is indicated instead of thoracotomy when an empyema 
has existed a sufficient time to cause the lung-tissue or the thoracic 
parietes to lose their normal elasticity and the pleura to become thick- 
ened and infiltrated with granulation-tissue and coagulable lymph. 
Under such conditions no operation except thoracoplasty holds out any 
hope of permanent cure to the patient. It is thus evident that thoraco- 
plasty is an operation to save life only in those cases where thoracentesis 
and thoracotomy have failed to effect a cure, and to offer a hope of 
recovery in cases hitherto considered fatal. 
Calcification of the pleura has been observed in connection with 
disease of the rib. Fig. 126 illustrates this disease of the pleura, for 
which no surgical operation can be undertaken unless the lesion is cir- 
cumscribed. The writer has also recently observed a case of multiple 
fibroid nodules studding the parietal layer of the pleura. 
Tumors of the Thorax. 
Tumors of the thorax may be situated upon the thoracic wall or 
involve the bony parietes, the viscera, or the mediastinal nodes. Gurlt 
collected 14,630 tumors from several hospitals, and of this number 104 
grew from the thorax. 
The neoplasmata affecting the external surface of the thorax may be 
benign or malignant. The former class includes lipoma, fibroma, chon- 
droma, osteoma, neuroma, and the latter sarcoma and carcinoma. The 
benign growths may take their origin from the soft parts. It is of the 
greatest importance to distinguish between those which grow from the 
external parts and those which take their origin from within and present 
externally by forcing their way through the cliest-wall. The question 
should be carefully considered before undertaking any surgical opera- 
tion. 
The tumors that most likely arise from the external soft parts are the 
lipomata, which grow from the subcutaneous fatty tissue which abounds 
so plentifully upon the back and sides of the thorax. The lipoma in 
this situation is generally pedunculated, attains only a moderate size, and 
is freely movable under the skin, which can be usually gathered up in 
wrinkles over it. The tumor is painless unless it embraces a nerve-fila- 
ment or becomes inflamed. 
Lipoma is the most frequent benign growth which is found upon the 
thorax. It is usually situated upon the back of the chest, notably 
between the scapulae, and takes its origin from the fatty tissue which 
appears in such abundance in this situation. Billroth reported the 
removal of one from this situation which was equal in weight to about 
one-third of the body. 
Lipomata are occasionally found upon the front of the thorax, and especially 
behind the mammary gland. These retromammary lipomata have been known to 
cause death by causing hypertrophy and dilatation of the heart. These lipomata, 
on the other hand, have grown outward, and caused by pressure an ulceration of 
the skin upon the front of the chest. Small multiple lipomata springing from the 
subcutaneous adipose tissue are often observed, and Le Gros Clark reports having PLATE VII. 
Neuro-fibroma of Skin. TUMORS OF THE THORAX. 
291 
removed a lipoma which was situated beneath the pectoralis minor muscle. The 
writer has frequently seen a case of multiple lipomata of the chest with a large 
lipoma situated upon the buttocks, the size of which exceeded that of the man’s 
head. 
Fibromata are also found upon the chest-wall. They are of two vari- 
eties, one of which is hard and slow-growing and less movable than the 
lipoma, and springs frequently from the axilla, and also beneath the pec- 
Fig. 127. 
Neuroma of intercostal nerves (Riedinger). 
toralis major muscle. The other variety is soft, multiple, and usually 
congenital, and termed fibroma molluscum. There are no metastases 
from this growth, although regional recurrence sometimes is found 
(Plate VII.). 
These fibromata may be pedunculated or sessile, and in either case raised well 
above the surface of the skin. 
Keloids are sometimes observed upon the sternum, and occasionally assume the 
characteristics of the recurrent fibroid tumor of Paget. 
Chondroma of the chest takes its origin from the sternum, ribs, 
and cartilages. The tumor is hard, solitary, painless, and slow-growing 
unless it partakes of cystic degeneration, and usually occurs during adult 
life. 292 
SURGERY OF THE CHEST. 
The chondroma, if pure, is benign, but, unfortunately, the growth is found to 
be associated with sarcoma, in which case it is highly malignant. It must not be 
forgotten that in exceptional cases the chondroma may grow inward and involve 
the pleura or the diaphragm. 
Traumatism seems to explain the origin of chondroma of the ribs, since the 
tumor has been observed to start from the seat of a fractured rib. 
Fig. 128. 
Sarcoma of rib and pleura, result of injury by a base-ball. 
Neuroma may be found on the chest-wall, and it grows from one of 
the intercostal nerves. 
Echinococcus of the sternum lias been observed in a few cases, and 
also dermoid cysts. They are, however, so rare that they are mere 
surgical curiosities. TUMORS OF TIIE THORAX. 
293 
Osteomata grow from the bony structure of the thorax. They are 
hard as bone itself and do not form secondary deposits. 
Sarcoma is found upon the thorax, but usually it has an intra- 
thoracie origin, having made its way through the parietes. The tumor 
grows rapidly, soon forms a fungous mass, and causes metastases. In 
the early stage the growth appears hard and nodulated, and admits of 
little movement under the skin, which very soon becomes discolored 
and ulcerates. The growth may appear upon the front or in the axil- 
lary region. 
The writer has recently operated on a case of sarcoma which was situated upon 
the axillary aspect of the chest. The patient was fifteen years of age, and was 
struck over the site of the tumor by a base-ball. Three months later a well- 
defined, hard tumor was present, with firm adhesions to the rib. The tumor was 
removed together with the rib to which it was attached, and also the underlying 
pleura, which was also involved. The lung itself was not implicated in the 
growth. The accompanying wood-cut shows the appearance of the tumor at the 
time of operation or three months following the trauma. (Vide Fig. 128.) 
Sarcoma may grow also from the sternum. The writer has seen 
several of these cases, but in each case the tumor was situated upon the 
manubrium and had perforated the bone. It is a question whether 
these sarcomata grew from the connective tissue behind the sternum 
and perforated the bone or from the periosteum upon the front of the 
sternum. In either case the prognosis is not favorable. 
G-ummata are found on the chest-wall: they appear as indurated 
swellings just beneath the skin. These tumors appear in the tertiary 
stage of syphilis. The skin over the swelling soon becomes cyanotic, 
denoting a disturbance in the nutrition of the skin. This condition 
soon leads to the formation of an ulcer. In rare eases the ulcers 
undergo absorption, leaving behind a thickened fibroid mass. In the 
active stage the mass contains in the centre cells which rapidly undergo 
fatty change, while upon the periphery of the tumor is a network of 
blood-vessels, and between this layer and the softened nucleus within is 
a matrix imbedded in which are numerous cells. The breaking down 
of the gumma in its interior is attributed to a want of blood-supply 
induced by thrombosis of the vessels surrounding the periphery of the 
mass. These gummata may be situated in the periosteum of the ribs 
and sternum, and even upon the scapula. They usually cause caries of 
the respective bones. They may also be situated in the substance of 
the muscles. They are usually unilateral, chronic in their course, and 
may cause metastasis in the lung. 
The ulcers from syphilis are generally situated upon the sternum 
and form deep excavations leading down to exposed bone. 
The treatment consists of the administration of iodide of potash 
and mercury, conjoined with mercurial baths. Mercury must not 
be employed to the extent of salivation or in chronic Bright’s dis- 
ease. Under any circumstances the administration of the drugs men- 
tioned must be carefully watched. If the gumma has begun to break 
down and ulceration is present, the ulcer can be scraped and antisyphi- 
litic remedies immediately employed. The removal may even expose 
the pleura or pericardium. The use of a bichloride solution for irriga- 
tion and the dressing of the base of the ulcer with iodoform are recom- 
mended. 294 
SURGERY OF THE CHEST. 
Tuberculosis of the chest-wall is occasionally observed. The dis- 
ease may be present in the form of an ulcer or a cold abscess. If the 
former is the case, the caseation of the mass usually follows. Some 
parts of the tuberculous mass may undergo calcification. This break- 
ing down of the tuberculous nodule may be followed by an abscess to 
which reference has just been made. 
The condition calls for radical surgical treatment, since general 
tuberculosis may follow from this focus. The disease may also produce 
caries of the ribs or sternum, just as gummata will cause these changes 
in bones. 
The tuberculous nodule is situated in the subcutaneous tissue, and from the mass 
long sinuses lead outward which are lined by unhealthy granulations. The sinuses 
may be very tortuous and extend for a long distance beneath the skin. Occasion- 
ally the tuberculous nodule may take its origin in the subperiosteal instead of the 
subcutaneous tissue, in which case there is danger of visceral infection. 
The treatment of tuberculous ulcers upon the chest call for practi- 
cally the same local measures as are indicated in gummatous idcers. 
Tonics should be employed, but not the potash and mercury as in syph- 
ilis. Out-of-door life, physical exercise, and sea-bathing are among the 
means suggested to improve the general health. 
Actinomycosis affects the chest-wall. The disease begins upon the 
thorax and extends inward until the lung becomes involved. The con- 
dition gives rise to a fistula which has been mistaken for tuberculosis. 
(Vide Yol. I. p. 156.) 
The signs and symptoms of actinomycosis of the chest-wall con- 
sist of the presence of a hard lump over which the skin has become 
cyanotic. The integument soon sloughs and a peculiar discharge con- 
taining yellow granules escapes. Into the mass numerous tortuous 
sinuses are seen, and from these sinuses the characteristic yellow dis- 
charge flows. The presence of much liquefaction indicates the activity 
of the fungus, while granulations springing up point to the death of the 
fungus. 
The treatment of actinomycosis of the chest-wall consists of ex- 
cising the indurated and sloughing mass and scraping with a curette the 
sinuses, and then applying the actual cautery. The use of bichloride 
of mercury as an antiseptic irrigation is highly extolled. Gautier 
injected a solution of iodide of potash into the indurated mass, and then 
passed a galvanic current through it. This liberated the nascent iodine 
into the tumor and destroyed the actinomycoses. 
Carcinoma may be situated anywhere upon the front of the chest 
and also in the axilla. The disease begins upon the skin and ulcerates 
its way into the deeper tissues. The mode of origin is different from 
that of sarcoma, which usually begins under the skin and grows exter- 
nally. The axillary carcinoma is usually secondary to breast carci- 
noma, although in two instances the writer has seen primary carcinoma 
in the axillary glands. 
The tumor grows rapidly, is attended by pain and cachexia, and soon 
gives rise to metastatic deposits. The ulcer bleeds, has an irregular edge, 
and is covered with a discharge. The tumor is usually situated over the 
sternum, and is immovably connected with the subjacent structures. 
The TREATMENT of tumors involving the external surface is early TUMORS OF THE TIIORAX. 
295 
excision, with removal of the nodes if the growth is malignant. The 
treatment of tumors of the breast is not considered, for a full descrip- 
tion of which the reader is referred to the chapter on Diseases of the 
Mammary Gland. 
The lipoma and fibroma are easily excised. The chondroma occasionally 
demands removal of the corresponding rib, especially if it grows rapidly, in which 
case the tumor should be removed by a flap incision. The small, slow-growing 
chondroma seldom demands surgical interference, and the character of the tumor 
is such that the risks of an operation are greater than those of the presence of the 
tumor itself. 
Osteoma seldom calls for surgical interference, since it is not malignant and 
never gives rise to secondary deposits. 
In the removal of sarcoma and carcinoma a radical operation is demanded. The 
growth should be freely excised and any infected nodes removed. In these two 
varieties of malignant tumors the base of the ulcer should be thoroughly cauterized 
with a Paquelin cautery. If this is employed, ether must not be used, since an 
explosion might occur and suffocate the patient. 
In concluding the subject of tumors of the outer surface of the thorax the 
possibility of an aneurism must be considered. The writer has seen two cases of 
aneurism of the innominate artery which have bored their way through the upper 
part of the sternum and presented themselves in the form of a tumor having the 
size of a child’s fist. The characteristic signs of aneurism serve to distinguish this 
tumor from neoplasmata, and the withdrawal of pure blood by an aseptic hypo- 
dermic needle will establish with accuracy the diagnosis. 
Tumors of the mediastinum are frequently observed. Like 
tumors of the extrathoracic variety, they may be divided into benign and 
malignant. Among the former are lipoma, fibroma, enlargements of the 
mediastinal nodes, together with the dermoid and hydatid cysts, which 
are not, strictly speaking, tumors, and also the growths connected with 
the thymus. Among the malignant tumors may be mentioned sarcoma, 
carcinoma, and lymphoma. 
The lipoma and fibroma and the other benign swellings are not, as a rule, sus- 
ceptible of removal unless they present externally, as they sometimes do, in which 
case great care must be exercised in their removal. The malignant tumors call for 
operation if situated in accessible areas. 
Sarcoma is the malignant tumor of the mediastinum, which is second in point 
of frequency, according to Hare, who places carcinoma first. 
Sarcoma of the mediastinal nodes may be primary, although it often 
occurs as a metastatic deposit from the pleura or from the breast or from 
the abdominal organs. In the latter case the deposits are carried by the 
blood-vessels or by lymph-channels through the oesophageal opening in 
the diaphragm. Sarcoma may also atfect the mediastinal nodes by sec- 
ondary deposit from sarcoma of the humerus, while sarcoma of the 
thigh affects but the lumbar, pelvic, and abdominal nodes. Sarcoma, 
unlike carcinoma, may affect simultaneously different organs and struc- 
tures in the body—a clinical fact to be borne in mind as a distinguishing 
feature from carcinoma. The signs of sarcoma of the mediastinal nodes 
are lancinating pain, cough, aphonia, cyanosis, dyspnoea, epistaxis, tin- 
nitus aurium, dysphagia, palpitation of the heart with angina pains, oedema 
of the cervical region due to obstruction in the venous return, dropsy of 
the serous cavities. Displacement of the heart also occurs, with some- 
times oedema of the lower extremities. If the tumor irritates the pneu- 
mogastric or phrenic nerves, the usual functional disturbance is present. 
The physical signs show a marked difference as contrasted with 296 
SURGERY OF THE CHEST. 
simple and purulent effusions in the serous cavities or with a chronic 
non-resolving tuberculous pneumonia. 
The differential diagnosis between mediastinal tumors and 
aneurism is often most difficult, and at times in the early stages of 
the respective diseases almost impossible, inasmuch as either of the two 
affections is capable of duplicating any of the physical signs produced 
by the other. 
Carcinoma of the mediastinal nodes presents many signs identical with those just 
given in connection with sarcoma. This variety of malignant disease stands first 
in point of frequency. The situation of the tumor is generally in the anterior 
mediastinum. The disease occurs in adult life, and may be primary or secondary 
to mammary carcinoma. The disease may originate primarily in the tracheal or 
bronchial nodes or in the remains of the thymus gland, from the periosteum of 
the posterior surface of the sternum, or in the abundant connective tissue in the 
anterior mediastinum. 
The tumor has been observed to take its origin even from the pulmonary tissue 
itself. 
The medullary variety is most frequently seen, and next the scirrhous or col- 
loid ; the two latter kinds, however, form only a A7ery small percentage of the cases. 
The treatment of malignant tumors involving the mediastinum con- 
sists of removal of the neoplasmata if they are situated in accessible 
areas. The tumor can be excised if it presents externally by the use of 
the knife and Paquelin’s cautery. 
If the tumor is situated posteriorly, it can be removed by a method 
described by Bryant, for a full description of which the reader is re- 
ferred to the Transactions of the American Surgical Association for 
1895. 
Sarcoma and carcinoma of the lung are the malignant tumors affect- 
ing this organ. The accompanying figure shows a typical carcinoma of 
the lung. The disease in this case is secondary to carcinoma of the 
pelvis. 
The diagnosis of malignant neoplasm of the lung is almost 
impossible in the incipient stage of the growth, since many other con- 
ditions at the beginning give rise to similar physical signs. 
The only positive means of diagnosis is by an examination of particles of the 
tumor which have been obtained by expectoration, as in abscess of the lung. This 
occurrence is extremely rare, since only four well-authenticated cases have been 
published. Particles of lung-tumor may be obtained for microscopical examina- 
tion bv means of the harpoon. There are two such cases recorded. The examina- 
tion of the fluid in the pleural cavity has also been employed as a diagnostic test 
in tumor of the lung. Quincke has demonstrated that the presence of such a 
pleuritic effusion as hydrops adiposus points to the presence of cancer, since fatty 
cells seldom, if ever, are found in pure inflammatory exudations, unless occasion- 
ally in tuberculous effusions. 
Pneumotomy lias been employed to remove these neoplasms. It is 
only when the growth is situated upon the periphery of the lung and 
the diagnosis is certain that operative interference is justifiable. Andrews 
of Chicago in 1892 exhibited to the Chicago Medical Society several 
pulmonary concretions which were removed by pneumotomy. 
Tumors affecting the pleura consist chiefly of carcinoma and 
endothelioma. The writer has seen one case in which the withdrawal 
of bloody serum twenty-four hours before death was the first evidence 
pointing to the malignant character of the disease. The condition was 
thought to be tuberculosis from the physical signs that were present, TUMORS OF THE THORAX. 
297 
especially as the mediastinal and cervical nodes were involved. The 
pleura may undergo calcification, so that the membrane is rigid, and 
the process is similar to that involved in calcification of an artery as it 
is seen in plaques. 
Dermoid cyst of the right pleura has been observed, in which the cyst set up an 
empyema and had a communication with the bronchus, from which the patient 
coughed up hair. Lipoma has also been observed growing from the parietal layer. 
Tumors of the lung are seldom primary. They are usually secondary to 
malignant disease of the breast. Under the circumstances no operative interfe- 
rence is indicated. 
Tumors of the lung- consist of carcinoma and sarcoma. The former 
is generally secondary to carcinoma of the breast or the mediastinal 
nodes. Sarcoma is also usually secondary to the disease in some other 
part of the body. 
Tumors of the thoracic duct have been observed. These neoplasmata 
were secondary deposits from malignant disease of the testicle, uterus, 
Fig. 129. 
Sarcoma of lung, circumscribed. 
and also the lumbar nodes. In one case of carcinoma of the duct the 
disease was secondary to an undescended testicle. 
Tumors of the lungs may be divided into those which are benign and 
those which are malignant. The benign tumors seldom give rise to 
symptoms unless they become large enough to mechanically interfere 
with the function of the lung. 
Adenoma lias been described by Chiari. Lipoma, chondroma, adenoma, and 
osteoma are occasionally observed. But these benign neoplasms are chiefly of 
pathological interest and seldom call for surgical interference. It is often very 
difficult to decide whether a primary tumor had its origin in the lung and sec- 
ondarily invaded the pleura, or vice versa. 
Gummata are found in the lung in the form of multiple globular nodules. 298 
SURGERY OF THE CHEST. 
They may exist for a long time, and if small give rise to no special disturbance. 
The writer recently examined lungs in which several gummata were imbedded. 
In a few of the nodules the caseous material in the centre had become softened 
and broken down, and a distinct fibrous capsule formed of plastic exudation 
seemed to surround the mass—a condition not usually found in gummata. The 
capsule was formed of fibrous tissue similar to that surrounding a blood-clot. In 
these nodules the three characteristic zones were visible—the outer consisting of 
cells, the middle formed of fibrous tissue, and an inner zone made up of caseous 
material. 
The Diaphragm. 
The surgery of the diaphragm can be classified according to the plan 
pursued in the discussion of the other viscera. 
The consideration of the subject embraces the congenital defects, 
the injuries, the disease, and, finally, the tumors. 
The diaphragm is a muscle which separates the thoracic from the abdominal 
cavities. Posteriorly the muscle is attached to the vertebral column, and laterally 
and anteriorly to the thoracic walls. 
Upon the right side the muscle rises to a level with the third cartilage during 
a forced expiration, and descends to the level of the fifth intercostal space during 
a forced inspiration. Upon the left side the diaphragm descends to a point a little 
lower down. 
The diaphragm has been observed to ascend as high as the second rib in cases 
of extreme distention from intestinal tympanitis, and it has been found to descend 
even below the false ribs in pleuritic effusions. 
The muscle has a serous lining upon both its thoracic and abdominal surfaces. 
In the former case the pleura affords a lining, and in the latter the peritoneum. 
This anatomical fact serves to explain the peculiar character of the inflammatory 
affections of the diaphragm. 
The congenital defects of the diaphragm consist of fissures which 
permit the escape of the abdominal viscera into the thoracic cavity. 
The condition is rapidly fatal, since strangulation soon occurs. The 
accompanying figure shows a case of congenital diaphragmatic hernia in 
which the viscera have ascended through a fissure in the diaphragm into 
the thoracic cavity. 
Treatment by laparotomy is indicated, provided the diagnosis can 
be established, but as the infant dies very soon after birth, no operative 
treatment can be undertaken. 
Injuries of the diaphragm consist of gunshot wounds, stab wounds, 
and rupture. 
Gunshot wounds of the diaphragm, as well as stab wounds, present 
nothing of the interest which attaches to these wounds in other parts. 
The injury is serious, because the associated abdominal or thoracic 
lesions render the prognosis exceedingly fatal. Laparotomy is indicated 
if the diagnosis can be made approximately certain. 
Rupture of the diaphragm is caused usually by some form of trau- 
matism, by muscular action, or by the bursting of a liver-abscess. This 
lesion may occur with or without any corresponding injury to the integ- 
ument. The rupture occurs, as a rule, through the fleshy part of the 
muscle, and also, as a rule, upon the left side, because the liver affords 
protection upon the right side. 
The signs of rupture of the diaphragm are a rapid, irregular pulse, 
which is due to a disturbance of the pneumogastric nerve; a character- 
istic manner of respiration, which follows an exaggerated action of the THE DIAPHRAGM. 
299 
accessory thoracic muscles ; quiescence of the diaphragm during respira- 
tion ; a depression of the epigastric and hypochondriac regions; severe 
pain and persistent vomiting, both of which are increased by hiccough 
or coughing. If the stomach or intestine ascends through the torn part, 
there is an abnormal tympanitic resonance, with a loss of the normal 
Fig. 130. 
Congenital diaphragmatic hernia (Wood Museum). 
respiratory murmur. If fluid is taken into the stomach, a succussion- 
sound is heard by auscultation. The facies denote severe internal injury. 
If the rupture has occurred as a result of the bursting of a liver- 
abscess, there have been as premonitory symptoms temperature and 
jaundice. Following quickly upon rupture signs of pleurisy appear. 
Tympanitic resonance is heard over this area if the stomach or a coil of intes- 
tine has forced its way upward through the rent. The respiratory murmur is 
altered in consequence of the transposition of the above-named viscera. 300 
SURGERY OF THE CHEST. 
Auscultation reveals the presence of a succussion-sound after imbibition of fluid. 
This sign is very similar to the metallic tinkle pathognomonic of air and fluid in the 
pleural cavity. Shaking the patient causes the splashing of fluid in the stomach, 
which can be heard if the ear of the surgeon is placed at this point. 
Facial expression is pathognomonic, since it denotes great physical suffering. 
Following very soon upon these signs, those indicating the onset of pleurisy and 
peritonitis are observed. In only 10 per cent, of the cases is there absence of a 
visceral hernia. 
The treatment consists in an immediate laparotomy, the performance 
of which has been successful in at least 8 reported cases. Postempski 
operated in 1 case in which an omental hernia was present, the reduction 
of which, together with the suturing of the rent, terminated successfully. 
The laparotomy should be performed early, in order to avoid the 
dangers of the shock of a delayed operation, and also to avert an im- 
pending pleurisy and peritonitis. 
The diseases of the diaphragm are very few. The chief one is 
paralysis of the muscle, due to the peripheral lesion of the phrenic 
nerve. The diaphragm may also be affected in consequence of a dia- 
phragmatic pleurisy or peritonitis, or from toxic influences, such as 
diphtheria and lead-poisoning, or even from suppuration in the form of 
a subphrenic abscess, a discussion of which has already been considered. 
Hysteria may also cause paralysis of the diaphragm. 
The symptoms of paralysis of the diaphragm are loss of movement 
of the muscle during the respiratory act, an increase in the number of 
the respirations, a depression in the epigastric and hypochondriac 
regions, and dyspnoea. Paresis of other muscles is present if the lesion 
is central, and if this muscle alone is affected, the cause is due to a 
lesion of the phrenic nerve. 
The treatment of paralysis of the diaphragm consists in the 
administration of iron and strychnia, in galvanism, and in the use of any 
antidotes to a poison such as lead, or antitoxin in case of diphtheria. 
Tumors of the diaphragm are exceedingly rare as a primary affec- 
tion, although tumors affecting the viscera may cause disturbance which 
may even lead to rupture of the muscle. 
In these cases the signs indicative of rupture are present, but the 
onset of the symptoms are not sudden, as in rupture due to traumatism. 
As the symptoms develop slowly, the patient becomes more or less 
accustomed to the altered conditions, and the phenomena are not so well 
pronounced. 
Diaphragmatic hernia may occur in consequence of a congenital 
fissure or from a tear in the muscle due to traumatism. The injury may 
be caused by a broken rib or by muscular action. The seat of the lace- 
ration is nearer the posterior than the anterior part, and usually upon 
the left side on account of the presence of the liver upon the right side. 
The stomach and transverse colon are the parts usually found in the 
hernial sac. 
In addition to the traumatic variety of hernia, a spontaneous variety 
may occur in which the viscera enter the thoracic cavity through one of 
the natural openings of the diaphragm. The left side is the usual seat, 
since the liver occupies by its convex surface the vaulted part of the 
diaphragm. The opening is generally between the xiphoid cartilage and 
the costal interspaces. THE (ESOPHAGUS. 
301 
The symptoms of strangulated diaphragmatic hernia are those 
already observed in this condition, together with the presence ot a 
tumor in the thoracic region, accompanied by the signs of dyspnoea. 
The TREATMENT of diaphragmatic hernia due to injury is laparotomy, 
as has already been mentioned. If the hernia is due to congenital 
defects, no operative interference is of avail. If due to the spontaneous 
variety, in which the viscera ascend through one of the natural but now 
dilated openings, laparotomy is indicated, provided the diagnosis can 
be established. 
The (Esophagus. 
The surgical anatomy of the oesophagus is important in order to understand the 
operations upon this part. It is a continuation of the pharynx, and begins oppo- 
site to the sixth cervical vertebra at the lower border of the cricoid cartilage, and 
extends downward through the mediastinum and diaphragm to the upper border 
of the eleventh dorsal vertebra, at which place it enters the stomach. The tube is 
about nine inches in length, and begins in the median line, and then soon inclines 
to the left side at the root of the neck. It then returns to the median line, and 
finally deviates again to the left side to perforate the diaphragm. The narrowest 
part of the tube is opposite to the fourth dorsal vertebra, although it becomes very 
narrow opposite the diaphragm. 
In the neck, the oesophagus has in front of it the trachea, and a little lower 
down, where it deviates to the left, the thyroid body and thoracic duct, and behind 
it rests upon the front of the bodies of the vertebrae upon which lies the longus 
colli muscle. The oesophagus has upon its side the common carotid artery and the 
lateral lobes of the thyroid body. The recurrent laryngeal nerve runs in a groove 
between the oesophagus and the trachea. The surgical relations are of special inter- 
est as the oesophagus descends to enter the thorax. The tube descends posterior 
to the transverse arch of the aorta, and as it passes down through the posterior 
mediastinum it descends upon the right side of the aorta to the opening in the 
diaphragm, at which point the tube passes in front of and a little to the left side 
of the aorta to enter the abdominal cavity. 
The oesophagus has in front of it at this point the trachea, the left carotid and 
subclavian arteries, the pericardium, the left bronchus, and the arch of the aorta. 
It has behind it the bodies of the vertebrae covered by the longus colli muscle and 
the intercostal vessels. It has also the aorta behind it in the lowest part of the 
canal. 
Upon the sides the pleurae cover the oesophagus, and upon the right side is found 
the vena azygos major and upon the left side the descending aorta. The right 
pneumogastric nerve passes down behind, and the left pneumogastric in front of 
the oesophagus. The two vagi, together with the branches coming from the first 
dorsal ganglion of the sympathetic, form a plexus in front of the oesophagus extend- 
ing from the root of the lungs to the stomach. 
The oesophagus has three coats. The outer or muscular coat is divided into 
longitudinal and circular layers, between which lies a plexus of nerves. The 
middle or areolar coat is composed of loose elastic connective tissue in which is 
imbedded rows of compound racemose glands and adenoid tissue. 
The inner or mucous coat is arranged in vertical rugae or folds, and is covered 
by pavement epithelium, beneath which are imbedded irregular rows of papillae. 
Between the mucous coat and the middle coat in the lower segment of the 
oesophagus is a special coat which has been called the muscularis mucosae. 
Malformations of the oesophagus occasionally are observed, and are 
due to incomplete closure of the branchial clefts. There have been 
about seventy-five cases reported in surgical literature. 
The oesophagus maybe entirely absent. MacKenzie has reported 14 
cases of this kind. The upper and lower part of the canal were present, 
and the two parts were connected with each other by a cord. In some 
cases a communication is observed between the trachea and the oesopha- 302 
SURGERY OF THE CHEST. 
gus to which the term traeheo-oesophageal fistula has been given. Dila- 
tation of the canal is observed in cases where fatty degeneration of the 
muscular fibres has taken place. 
Dilatation of the oesophagus may be localized, in which case a diver- 
ticulum is formed, or it may be general and involve the whole length of 
the canal. If the condition is not congenital, the cul-de-sac is caused by 
nature endeavoring to force downward food through a stricture. The 
pouch is thus formed by a stretching of the oesophageal walls just above 
the point of obstruction. 
'Operations have been performed successfully from the neck with a view to 
obliterate the pouch. The cul-de-sac has been dissected away, and the wound in 
the oesophageal wall closed with sutures. The pouch is called a pliaryngocele. The 
presence of the pouch is most annoying to the patient, since food often collects in 
it and gives rise to paroxysms of coughing, and often induces the disagreeable 
sensation of choking. In some rare cases death has occurred in consequence of 
choking. 
Diverticula of the oesophagus may occur by distention from within 
or by traction from without. The diverticulum formed from distention 
is usually found in the extreme upper part, and has been considered a 
hernial protrusion of the mucous membrane through the separated fibres 
of the inferior constrictor muscle. This condition presupposes some 
pathological changes in the walls of the oesophagus. 
There are between fifty and sixty cases of this kind scattered throughout sur- 
gical literature. In this variety of diverticulum the symptoms are not pronounced 
until the pouch is distended with food, which enables the patient to swallow with 
some degree of comfort. Vomiting, regurgitation of food, and dysphagia are com- 
mon symptoms. The distended diverticulum can be emptied by external manipu- 
lation. If this is not done, the food undergoes fermentation and the breath 
becomes extremely offensive. The passage of an oesophageal bougie will make 
clear the nature of the trouble. The sound passes into a pouch or sac in the upper 
part of the oesophagus and becomes arrested, while in case a stricture is present 
the bougie will pass with difficulty into the stomach and the operation followed by 
regurgitation of bloody mucus. The obstruction is usually situated lower down, 
and has present many other signs characteristic of malignant disease. 
The traction diverticula are seen in adhesions of tumors to the walls 
of the oesophagus. The development of the growth causes the canal to 
be pulled aside, and subsequently the walls of the canal and the 
neoplasm become blended in one mass. Aneurism may also pull the 
oesophagus to the side, and by dragging upon the walls cause a divertic- 
ulum to be formed. This variety of diverticulum is also observed in 
connection with cicatricial contraction in tuberculosis of bronchial and 
mediastinal nodes; also from ulceration due to the presence of a for- 
eign body. 
In the treatment of these cases little has been accomplished by 
sounds, special alimentation, and gastrostomy. Recently operations 
have been performed with a view to excision of the diverticulum, and 
either closing the wound in the oesophagus with sutures or packing it 
and allowing it to heal bv granulation. Some surgeons suture the 
oesophageal wound and pack the cervical wound until the danger of 
extravasations has passed. 
The treatment is substantially the same in the second variety of 
diverticulum, except when ulceration is present, in which case the 
oesophageal wound cannot be sutured. THE CESOPHAGUS. 
303 
Wounds of the oesophagus occur externally in consequence of 
injuries, and internally by the action of sharp-pointed foreign 
bodies. 
The wounds by external injuries are caused by stab, bayonet, and 
pistol-shot wounds ; also in cut-throats. 
The wounds by internal injuries are caused by the passage of sharp 
instruments and by foreign bodies. Pins, needles, and dental plates 
cause ulceration of the mucous membrane. In one case, the specimen 
of which is in the Wood Museum, a small plate of false teeth was swal- 
lowed by accident, and became lodged in the oesophagus and idcerated 
through into the pericardium. (Esophageal probangs have injured the 
walls to such an extent as to cause fatal results. 
In external wounds of the oesophagus in which a large opening is 
made the diagnosis is attended 
with no difficulty, but in small 
wounds, such as stab and gunshot 
wounds, the precise extent of the 
injury is often difficult to deter- 
mine. In the former case the 
presence of saliva or food in the 
cervical wound makes the diagno- 
sis positive, and in the latter case 
regurgitation of blood, intense pain 
accompanied by hiccough, dyspha- 
gia, and dyspnoea make the diag- 
nosis more than probable. The 
associated injuries, such as per- 
foration of the mediastinum and 
pleura, or a wound of the bronchial 
tubes, give rise to special signs 
pathognomonic of the lesion. 
The treatment of the external 
wound of the oesophagus consists 
in either leaving the wound open, 
packing it with gauze and feeding 
by an oesophageal tube, or else 
suturing the tear in the walls and 
providing for drainage in the cer- 
vical wound by iodoform gauze for 
a few days. 
In the internal ivound of the 
oesophagus rest and nutrient ene- 
mata are indicated; but if perforation has occurred, the conversion of 
the internal wound into a complete external wound and disinfection are 
the proper methods of treatment. 
In rare cases gastrostomy is called for, and the patient nourished a 
sufficient period to allow the wound in the oesophagus to heal. 
Rupture of the oesophagus has occurred in consequence of severe 
vomiting. There are about twenty-five cases reported in surgical liter- 
ature. It is generally believed that in these cases of rupture the mus- 
cular walls of the canal were rendered weak from fatty degeneration. 
Fig. 131. 
Piece of sausage lodged in oesophagus just below 
the epiglottis, causing instant death (Wood 
Museum). 304 
SURGERY OF TIIE CHEST. 
The rent in the canal is usually a linear one and involves chiefly the 
mucous membrane. 
Yon Ziemssen and Zenker believe that the walls of the oesophagus are softened 
by excessive use of alcohol, and that the presence of softening is a necessary con- 
dition to rupture. 
Rupture of the oesophagus is attended by violent pain, following upon an 
attack of vomiting, usually to dislodge a foreign body. Collapse at once occurs 
and vomiting of blood is present. Cervical emphysema appears, and the patient 
dies in a few hours. If the diagnosis can be made, external oesophagotomy is the 
proper plan of treatment, but as yet no case has recovered. 
Perforation of the oesophagus from other causes than traumatism 
occurs as a result of peptic or other ulcers, malignant disease, foreign 
bodies, and from diseases connected with the mediastinum and pleura; 
also from pressure of aortic aneurisms. 
Fig. 132. 
Jack-stone lodged in oesophagus (Phelps). 
The treatment must necessarily vary according to the nature of 
the cause of perforation. An cesophagotomy is indicated*for the removal 
of foreign bodies, and a gastrostomy for malignant disease. In case of 
ulcer, rest, the use of the stomach-tube or rectal feeding, are among the 
means to be employed. 
Foreign bodies may be lodged in the lower part of the pharynx near 
the oesophagus. At this place pieces of meat, potatoes, apples, sausage, 
etc. are arrested on account of their size and volume. In the tonsils 
and the glosso-epiglottidean fold such foreign bodies as needles, pins, 
small fish-bones, etc. are often lodged. In every case the pharynx 
should be carefully examined, since the sensations of the patients are 
often misleading, as they are under the impression that they have swal- 
lowed the foreign body, when it is still caught in the fold of mucous 
membrane. The opposite condition sometimes prevails, and the patient THE (ESOPHAGUS. 
305 
thinks the foreign body is still in the throat, when in reality it has 
passed into the stomach. The bruising and laceration of the mucous 
membrane cause the same peculiar sensation as occurs when the body is 
actually impacted in the folds of mucous membrane. For these reasons 
it is always advisable to examine the throat carefully whenever the 
accident has occurred, irrespective of the sensations of the patient. 
Foreign bodies are also arrested opposite the fifth cervical vertebra 
and thyroid cartilage, and they may even descend lower in the oesopha- 
gus and become lodged in the walls of the oesophagus itself or at the 
cardiac extremity. 
The signs and symptoms of foreign bodies in the oesophagus vary 
according to the place of lodgement. If the body is of good size and is 
lodged in the upper part of the tube, choking and suffocation are the 
prominent signs. If in the lower part, the same symptoms are present, 
and pain is a constant symptom. Erosion of the mucous membrane 
soon supervenes, and sometimes a slight hsematemesis follows. 
The removal of foreign bodies lodged in the oesophagus is often 
attended with the greatest difficulty. The nature and character of the 
Fig. 133. 
(Esophageal forceps. 
foreign body, its exact lodgement in the gullet, and its shape and con- 
sistency are points to be considered in all attempts at extraction. 
Richardson has demonstrated that a foreign body which is found to be 141 
inches from the incisors is lodged at the cardiac end of the oesophagus ; if 9 inches 
below, it is behind the arch of the aorta. Any foreign body lodged 9 inches from 
the incisors is in a dangerous position, as Richardson has pointed out, since ulcer- 
ation into the vessel is imminent. 
Foreign bodies may be removed by instrumental means through the 
mouth, by external incision or oesophagotomy, and, finally, by gastrotomy. 
Before describing the operative measures a brief mention should be made of 
the employment of emetics for the purpose of dislodging any foreign body 
impacted in the oesophagus. As a rule, emetics for this purpose are to be con- 
demned, since perforation and even rupture of the oesophagus have occurred. If 
the foreign body have no sharp facets upon it and is small, the imbibition of food 
in the form of a large alimentary bolus has been recommended. This should not 
be done when the foreign body has sharp edges or is too large to pass through the 
pylorus or the ileo-csecal valve. The size of the foreign body is not so important 
as its shape, and also the fact whether it can be digested by the gastric juice. 306 
SURGERY OF THE CHEST. 
Instrumental means through the mouth consist in the use of the oesoph- 
ageal forceps, Yon G rate’s coin-catcher, and Sayre’s bristle or 
umbrella probang. Any and all of these instruments should be 
employed with great care, on account of the danger of perforation and 
rupture of the oesophagus itself, and also on account of laceration of the 
mucous membrane. Attention has been called by Richardson to impac- 
tion of the instrument itself, in which case no violence should be 
employed, but the removal should take place by a gastrostomy, for a 
description of which the student is referred to the chapter on Surgery 
of the Stomach. 
External cesophagotomy was first performed by Goursault in 
1773. The mortality of the operation formerly was very small, and 
the results since the introduction of antiseptic surgery are most brilliant. 
The incision is made upon the left side of the neck and along the 
anterior and inner edge of the sterno-cleido-mastoid muscle just below 
the thyroid cartilage. The larynx and trachea are upon the inner side 
and vessels upon the outer side. The skin, superficial and deep layer 
of the fascia superficialis colli, with the platysma myoides between them, 
are first divided. The fascia media colli and the fascia profunda colli 
are next divided. The sterno-cleido-mastoid muscle should be pulled 
aside and the omo-hyoid muscle divided. The descendens noni nerve 
must be protected from injury, as well as the recurrent laryngeal, 
which lies in a groove between the trachea and the oesophagus. The 
superior and inferior thyroid arteries must also be protected from 
injury. A male sound can be introduced through the mouth and the 
wall of the oesophagus divided upon the beak. Two curved needles 
armed with silk can be introduced through the oesophageal wall, and 
the incised wound held apart by an assistant in a manner similar to 
that employed in the urethra during external perineal urethrotomy. 
The wound in the neck thus held apart by retractors and the incision 
in the oesophageal walls by the silk, the interior of the oesophagus is 
open to free inspection and instrumental manipulation. 
The after-treatment of the wound may be conducted by two methods. The first 
consists of immediate suture with catgut for the purpose of obtaining primary 
union. The second is by granulation, which necessitates packing the wound 
with iodoform gauze. Whichever method is adopted, the patient must be fed for 
a few days by rectal enemata, or, if by the mouth, through a soft-rubber catheter. 
In some cases external cesophagotomy is employed in connection with gastrostomy, 
and foreign bodies are dislodged by the combined method, as suggested by 
Richardson. 
Internal cesophagotomy consists of the introduction of instru- 
ments into the canal for the purpose of dividing strictures. The 
instruments employed are made after the manner of urethral instru- 
ments and are used in much the same way. The operation is fraught 
with considerable danger, and nearly 25 per cent, of the cases have 
died. 
CEsophagismus, or spasm of the oesophagus, is observed in hysteria. 
This condition may also arise in connection with some reflex irritation, 
such as oesophagitis, or ulceration of the mucous membrane of the canal. 
The condition lias also been observed in connection with hemorrhoidal 
disease or associated with some functional disturbance of the liver. It 
has also been observed by Zenker and Ewald in brain and spinal-cord THE (ESOPHAGUS. 
307 
and kidney disease; also in neuralgia and pregnancy; and finally in 
cases of inflammation of the oesophagus or stomach and in gastric ulcer. 
(Esophagismus differs from any organic stricture in its intermittent character. 
If a bougie is introduced into the oesophagus, it meets with but little resistance as 
compared with that arising from an organic 
stenosis. If food is imbibed, regurgitation 
occurs immediately, and, in cases of organic 
stricture, after an appreciable interval. The 
patient often complains of globus hystericus. 
Fig. 134. 
The treatment consists of the in- 
troduction of the oesophageal bougie 
at regular intervals. In hysterical 
patients this operation often relieves 
the condition. Strychnine and iron anti 
atropine are indicated as tonics, and 
food which is simple and thoroughly 
masticated only is to be swallowed. 
Sea-bathing has also been highly ex- 
tolled. Faradization has been em- 
ployed with great benefit. 
Stricture of the oesophagus may 
be due to the presence of benign or 
malignant tumors, to chronic oesopha- 
gitis, to neuroses, to congenital defects, 
to ulcers, to cicatrices, and to pressure 
from without upon the tube. Stricture 
of the oesophagus due to malignant 
disease will be considered in connection 
with cancer and sarcoma of the oesoph- 
agus. 
When the stricture is caused by 
oesophagitis or by ulcer, rest and rectal 
feeding are the means to be employed ; 
if due to hysteria, the occasional use 
of the oesophageal probang, with the 
internal administration of drugs suit- 
able for the cure of that disease. 
As to congenital defects, little can 
be done, as the cases usually die from 
inanition in a few days. If due to 
cicatrices, division or divulsion of the 
stricture is indicated, and finally if to 
pressure by a neoplasm or an aneurism, 
nothing can be done if the aneurism or 
neoplasm cannot be treated. The cica- 
tricial stricture may occur in children 
in consequence of the imbibition of 
hot soups, or in adults by swallowing caustic alkalies or acids. The 
dangers of oedema glottidis must be remembered in acute inflammation. 
In introducing the oesophageal probang or sound the surgeon must 
exercise great care and gentleness, less irreparable damage may follow. 
Stricture of the oesophagus. 308 
SURGERY OF THE CHEST. 
The patient should be placed upon a low, firm stool with the head 
thrown well back. The surgeon should stand directly in front of the 
patient, and with his left fore and middle fingers introduced into the 
patient’s mouth depress the tongue, and guide the catheter or probang 
with the right hand along the index finger. As the instrument passes 
down the pharynx it should be carried a little to the right of the median 
line at this point, so as to avoid bringing the point against the epiglottis. 
When the instrument has cleared the pharynx it occa- 
sionally impinges upon the prominence of the fifth cer- 
vical vertebra near the level of the thyroid cartilage. 
If the slightest obstruction is met with, the patient’s head 
should now be inclined forward, and the probang will 
enter the stomach without any difficulty. 
If any stricture exists as a result of malignant disease, the 
caution cannot be too often repeated that the danger of perfora- 
tion is very great. In tubercular ulceration of the oesophagus 
the same warning is pertinent, since the walls are often very thin 
and a false and fatal passage can be made. 
The probang is used to detect foreign bodies and to examine 
for stricture. It may also be employed to relieve cesophagismus. 
The catheter is likewise employed for the purpose of feeding the 
Eatient in case of insanity or trismus. The soft-rubber catheter 
as also been used, and in some cases introduced into the stomach 
through the nostril. 
The treatment of oesophageal stenosis consists in 
the introduction of sounds made expressly for this pur- 
pose. The instruments employed for this object are pro- 
bangs with olive-pointed tips (Fig. 135); also steel bulbs, 
rubber bougies, and flexible hollow sounds, Whalebone 
guides are also used, and probangs with ivory or sponge 
tips. The olive-tipped probangs of various sizes are first 
employed in order to locate the density, the calibre, the 
length, and general extent of the stricture. The sur- 
geon should begin with a moderate-sized probang, and, 
finding the stricture, should change to a smaller or 
larger one according to the amount of resistance. 
Great care should be exercised lest a perforation is 
made, as the writer has known this accident to occur 
and with a fatal termination. 
If any shreds of tissue adhere to the instrument, which is 
especially the case with a sponge probang, they should be care- 
fully preserved and submitted to a microscopical examination. 
The passage of well-oiled olive-tipped probangs at regular 
intervals of every few days will dilate a cicatricial stricture or 
even cure the spasmodic variety, coupled with internal medica- 
tion consisting of tonics and antispasmodics. A malignant 
stenosis is in no way benefited by the constant use of sounds. The use of the 
probang in the latter condition is limited to diagnosis. 
Ewald has recommended the hypodermic injection of atropia and morphia 
before using the sounds, with a view to relaxing the muscles and to diminishing 
the quantity of saliva and mucus. 
The use of dilators like laminaria tents, etc. is open to serious objections, and 
is mentioned only to call attention to the damage which they inflict. 
Fig. 135. 
(Esophageal 
bougies. 
Retrograde dilatation of strictures of the oesophagus lias been THE (ESOPHAGUS. 
309 
performed by Richardson, Abbe, Murray, Lange, Franks, Loreta, and 
Schede, to the latter of whom is due the credit of suggesting this method 
by performing first a gastrotomy. 
Paralysis of the oesophagus occurs in consequence of lead-poisoning, 
alcoholism, and after certain infective diseases like diphtheria. The 
condition may also result from hysteria. 
(Esophageal hemorrhage occurs in connection with cirrhosis of the 
liver. Garland has recently reported a case in which the patient had 
repeated hemorrhages during a period of several years until a fatal one 
occurred. The source of the hemorrhage was from ruptured oesophageal 
veins surrounding the cardiac end of the canal. The rupture was the 
result of obstruction to the portal circulation. The writer has recently 
observed hemorrhage from the oesophagus in a case of obstructive jaun- 
dice with enlarged liver. The mouth and pharynx appeared perfectly 
normal, but the hemorrhage occurred at intervals, and finally disap- 
peared : but the patient quickly succumbed. 
McKenzie reports a fatal oesophageal hemorrhage in a boy suffering 
from varicose veins. 
Malignant disease of the oesophagus consists of sarcoma and 
carcinoma. 
These conditions are often diagnosticated by means of the cesopha- 
goscope, an instrument which is introduced into the pharynx and oesoph- 
agus for the purpose of examining the parts. The instrument can also 
be utilized for the purpose of detecting foreign bodies, as well as various 
changes in the mucous membrane which eventually give rise to stricture 
of the oesophagus. The oesophagoscope is used in connection with an 
electric light. The manipulation necessary to make a satisfactory exam- 
ination requires the services of one who has had considerable experience 
in the use of the instrument. 
Sarcoma of the oesophagus seldom occurs, since only about half a dozen cases 
have been reported. 
Carcinoma of the oesophagus is the malignant disease of this organ in over 
90 per cent, of the cases. The variety most frequently met with is squamous 
epithelioma. The cardiac end of the oesophagus is the most common seat, although 
the disease has been found throughout the entire length of the canal. 
The epithelioma may be secondary to carcinoma of the stomach or of the 
larynx or of the pharynx, or even of the tonsils. From these secondary deposits 
the bronchial and mediastinal nodes often become involved, also those of the 
trachea and liver. Epithelioma of the oesophagus is also primary, and takes its 
origin from the mucous membrane, which has become the seat of ulceration in con- 
sequence of impaction of foreign bodies, the irritation due to swallowing corrosive 
poisons, etc. The oesophageal canal may become perforated by ulceration, and an 
opening established between it and the trachea, or even into the large blood- 
vessels. The surrounding tissue often becomes infiltrated. 
Epithelioma rarely occurs before the thirtieth year of life, and is 
found most frequently between forty and seventy. Rebitzer states the 
average period as fifty-eight years. According to Butlin, it affects males 
more frequently than females, who are affected, as a rule, at an average 
period of ten years earlier. The disease runs a rapidly fatal course, 
and the patient expires in about six months from the beginning of the 
disease. The suffering from dyspnoea, thirst, difficulty of deglutition, 
and pain is often intense. Occasionally the course is less rapid, but the 
patient seldom survives eighteen months. 310 
SURGERY OF THE CHEST. 
The signs and symptoms of epithelioma of the oesophagus are 
difficulty in deglutition, both of fluids and solids, and, later, regurgita- 
tion of solid food, and subsequently fluids if the stenosis becomes very 
narrow. 
Pain is a constant manifestation of malignant disease of the oesopha- 
gus, and its intensity increases as the disease progresses. Regurgitation 
of bloody mucus often follows attempts at deglutition. The shreds of 
tissue regurgitated should always be subjected to a microscopical exam- 
ination, as often a positive and early diagnosis can thus be established. 
Stricture of the oesophagus soon becomes a serious symptom, and in 
some cases prevents the passage of all instruments, even though small 
quantities of fluids are imbibed and pass through the narrow opening. 
With these local signs certain con- 
stitutional symptoms soon super- 
vene, and the patient rapidly be- 
comes emaciated in consequence of 
loss of food and the constant pres- 
ence of pain. Inanition is only 
relieved by a gastrostomy. 
The treatment of malignant 
disease of the oesophagus admits 
only of oesophagectomy as a radi- 
cal operation, the mortality of which 
is very great. Gastrostomy is 
indicated as a palliative measure in 
those cases in which an oesopha- 
gectomy is impossible. The special 
technique in connection with oesoph- 
agectomy is as follows: 
CEsophagectomy consists of 
excision of a small segment of the 
oesophagus for the removal of ma- 
lignant disease. 
Fig. 136. 
Czerny, Park, and others have per- 
formed the operation on several occa- 
sions, but with only partial success, since 
patients have died a few months follow- 
ing the operation on account of the 
return of the disease. 
The steps of the operation are 
similar to those already described for external oesophagotomy, and after 
the segment is removed the lower open end is stitched to the cervical 
wound. The operation is not considered justifiable except where the 
segment to be removed can be reached by external oesophagotomy and 
no metastatic growths are present. The wound should be treated 
precisely as the wound following oesophagotomy, unless the segment 
excised is very small, in which case approximation of the ends can be 
accomplished. 
In union of the divided ends the edges must be united like the 
intestinal canal, and some mechanical device can be employed to help 
the surgeon. 
Epithelioma of oesophagus (Wood Museum). CHAPTER VII. 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, 
TONGUE, TEETH, AND JAWS. 
Arthur D. Bevan, M. D. 
Mouth. 
Anatomy and Embryology.—The mouth is bounded in front by the lips 
and behind by the soft palate and fauces. Its cavity is lined with mucous mem- 
brane covered by stratified epithelium. That portion covering the lips and 
cheeks contains glands of large size, labial and buccal, resembling the salivary 
glands in structure. These are sometimes the site of retention-cysts and other 
pathological processes. Opening into the mouth are the orifices of the salivary 
glands. The parotid duct (Stenson’s) is opposite the second molar of the upper 
jaw; the submaxillary duct (Wharton’s) on the side of the fraenum; and the 
sublingual ducts (the ducts of Rivini), eight to twenty in number, on the elevated 
ridge of mucous membrane on either side of the fraenum. 
The structures bounding the cavity and the mucous membrane covering them 
are very vascular, and therefore possess a high resisting power against invasion, 
and for the same reason repair rapidly after injury. The blood-supply is derived from 
the fascial, the internal maxillary, the lingual, and ascending pharyngeal arteries. 
The lymphatics are numerous. The superficial structures drain into the lymphatic 
nodes of the buccal submaxillary and suprahyoid groups; the deep into those of 
the internal, maxillary and upper cervical lymphatics. The nerves are supplied by 
the second and third divisions of the fifth pair of cranial nerves and the glosso- 
pharyngeal. 
From its embryological development the mouth-cavity is to be divided into two 
portions—one the upper end of the foregut, or primitive pharynx; the other the 
oral recess, or stomodceum. These are in very early embryonic life separated by 
a thin septum, which in the normal process of development disappears. An inter- 
esting point is that a part of the pituitary body is formed from the original mouth 
mucous membrane, which in the advancing development becomes entirely shut off 
from the mouth-cavity. Another point to be remembered is the fact that the cen- 
tral portion of the thyroid body is developed from the mucous membrane of the 
foregut, and that for a time the thyroid and mouth-cavity, or, at least, the base of 
the tongue, are connected by an excretory canal, the thyro-glossal duct. The 
remains of this duct are seen normally as the foramen caecum at the base of the 
tongue; as an abnormality of development a part of the thyro-glossal duct per- 
sists. In the early stages of development the foregut terminates blindly beneath 
the head; on the external surface of the embryo, in the space between the head 
and heart, the branchial arches gradually appear, and above these is a depression 
in the median line, the stomodceum, from which the mouth-cavity and nasal cavi- 
ties are formed. This depression is surrounded by a number of processes below 
the mandibular arch, from which the lower jaw and lower lip are formed. Above 
this, on each side, are the maxillary processes, from which the greater part of the 
upper jaw and upper lip are formed, and above these, and nearer the median line, 
the lateral and median nasal processes, from which the intermaxillary bone, the 
upper lip immediately in front of this bone, the septum, the external nose, and 
nasal cavities are developed. 
The mouth and nasal cavities are at first continuous; later, by the growing 
together toward the median line of the maxillary processes and the union of the 
middle nasal processes, the hard palate is produced and the mouth and nasal 
311 312 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
cavities separated. If in the process of development the maxillary processes fail 
to unite, a cleft remains, and we have the condition presented called cleft palate. 
This cleft maybe complete or partial, and may involve both hard and soft palate 
or but one or a portion of one of these structures. 
The intermaxillary bone is formed from the mesial nasal processes: these pro- 
cesses form also the portion of the upper lip in front of the incisors. If this cen- 
tral mass formed by the mesial nasal processes does not coalesce with the maxillary 
processes, the cleft remaining forms the condition of hare-lip. This condition may 
be present on one or both sides—in other words, single or double hare-lip. It may 
be limited to the soft tissues of the lip, or it may include the entire mesial nasal 
processes, in which case the intermaxillary bone would be entirely separated from 
the rest of the upper jaw, having in front of it the small mesial portion of the 
upper lip, and hanging suspended from the end of the vomer. Hare-lip and cleft 
palate are common : extensive cleft, extending from the mouth to the angle of the 
eye, occurs, but is rare; mouths so large or so small as to be classed as malforma- 
tions are also rare. The foregut is at first separated by a thin layer of epiblast and 
hypoblast from the stomodoeum ; this septum in the process of development dis- 
appears and the cavities become continuous; as a very rare malformation this 
septum persists and an imperforate foregut is the result. Malformations of the 
jaws, teeth, and tongue will be discussed under their respective heads. 
A clear understanding of the anatomy and embryology of the mouth 
is essential to the intelligent study of oral surgery. 
The study of the bacteriology of the mouth is of great interest to the 
surgeon. The relationship between mouth bacteria and local lesions of 
teeth and jaws and mucous membrane, of secondary gastric disturbances, 
and the study of the mouth as a point of infection for both local and 
general diseases, is a wide subject, and cannot be freely discussed in this 
practical text-book. Suffice it to say that normally the mouth contains 
scores of varieties of bacteria—more than one hundred have been iso- 
lated ; that these bacteria are for the most part saprophytic, but include 
also some common pathogenic forms, such as staphylococcus aureus and 
albus, pneumococcus, streptococcus pyogenes; that many of these bac- 
teria have the power of producing lactic acid and decomposition of dead 
organic substances; that dental caries is produced by such bacteria ; 
that pathogenic germs may be normal inhabitants of the mouth without 
injury to the individual; that when the resisting powers of the indi- 
vidual or of the local tissues are lowered to a sufficient degree these 
pathogenic bacteria may find a favorable breeding-ground for the pro- 
duction of disease. The mouth furnishes a point of infection for many 
pathogenic germs, such as those of diphtheria, erysipelas, actinomycosis, 
the oi'dium albicans of thrush, tubercle bacilli, and the virus of syphilis. 
It is probable that some of these germs, such as that of diphtheria, may 
be temporary guests in the mouth-cavitv without producing disease, 
probably finding either the local or general resisting power of individuals 
such as not to favor their development, and remain innocuous. (See 
Yol. I. Chapter III.) 
The examination of the mouth-cavity can usually be made without 
difficulty by inspection and palpation. A tongue-depressor is at times 
of service, a dental mirror is also occasionally useful, and in children a 
mouth-gag is often required. For this purpose a wedge-shaped piece 
of wood can be employed or such instruments as Heister’s, OThvyer’s, 
and Whitehead’s gags. 
Injuries of the Mouth.—The injuries of the mouth may be mechan- 
ical, chemical, or thermic. Mechanical injuries include incised, lacerated, CONGENITAL DEFECTS. 
313 
and perforating wounds. They should be treated as such wounds are in 
any portion of the body. They demand no special discussion beyond 
the reminder that the mouth-cavity contains at all times saprophytic 
and pathogenic bacteria capable of producing infection and decomposi- 
tion ; because of this fact wounds about the mouth cannot be placed in 
an absolutely aseptic condition; mildly antiseptic mouth-washes of 
boracic acid or bichloride of mercury should be frequently employed to 
render the cavity as nearly aseptic as possible. Burns and scalds of the 
mouth are not uncommon ; they are, as a rule, of mild degree, and 
demand nothing in the way of treatment except mild antiseptic mouth- 
washes. Extensive burns of the lips and the tissues of the face and 
neck result sometimes in great deformity of the mouth from cicatricial 
contraction, and require extensive operations for its correction. Chem- 
ical injuries result usually from the drinking of strong acids or alkalies. 
If the case is seen soon after the accident, a neutralizing agent, such as 
soda or vinegar, should be at once applied. The further treatment will 
be the use of a borax mouth-wash. Chemical injuries of the mouth due 
to chronic poisoning bv mercury, lead, and phosphorus will be discussed 
under the subject of Injuries and Diseases of the Jaws. 
Congenital Defects. 
The subject of hare-lip will be discussed in the section on the Sur- 
gery of the Face. 
Cleft palate is a congenital condition, as already explained, due to a 
failure of closure of the maxillary processes. Defects of palate struc- 
ture may result from trauma or disease, and demand the same surgical 
interference. Congenital cleft palate may involve both the hard and the 
Fig. 137. 
Whitehead’s mouth-gag (Dennis). 
soft palate, or but one of these structures; as a rule, both the hard and 
the soft palate are involved, and hare-lip also exists. The cleft in the 
soft palate is in the median line; that of the hard palate, when single, 
is a little to one side, and when double presents itself as a wide central 
cleft. The malformation seriously affects the function of speech, giving 
a peculiar nasal character to the speech characteristic of the difficulty. 314 
SURGICAL DISEASES AND INJURIES OE THE MOUTH, ETC. 
The alteration of the normal speech may be so great as to make the 
speech almost unintelligible except to those accustomed to the individual. 
This deformity has in some cases a marked effect on the life of its 
unhappy possessors, sometimes driving them to seclusion. In addition 
to the interference with speech, the cleft permits of the passage of food 
from the mouth to the nasal cavity, causing irritation and odor from the 
decomposition of the retained food-masses. Thrush often occurs in 
children with cleft palate. The problem presented by these cleft-palate 
cases is the closure of the defect so as to correct the speech and prevent 
the passage of food and drink from the mouth to the nasal cavity. This 
can be done in two ways—by a plastic operation with the purpose of 
closing the opening, or by an artificial obturator. Both of these 
methods have their advocates, some surgeons advocating the one method 
to the exclusion of the other. The author believes that both have their 
use, and should be employed according to the individual case : the arti- 
ficial obturator finds its special field of usefulness in acquired palate 
defects, the plastic operation in congenital cleft palate. Operations for 
closure of cleft palate are divided into uranoplasty, the closure of the 
hard palate, and staphylorraphy, the closure of the soft palate. 
The question as to how long after birth should the defects be closed is an open 
one. Many surgeons take the ground that hare-lip should be operated upon some 
time between the third and fifth months, and cleft palate left to the seventh or 
eighth year. There is a growing tendency to operate very early in these cases, 
within the first year of life, and there 
are many arguments to support this view 
—the fact that the defect in such a case 
is corrected before the child begins to 
talk, and the fact that in children who 
have learned to talk the closure of the 
defect does not, as a rule, improve the 
speech. The argument against operating 
in very early life is the difficulty of ma- 
nipulation in very small mouths, the greater danger to the patient, and the fact that 
at seven or eight the after-treatment can be easier carried out than in an infant. 
Fig. 138. 
Retractors for lips or mouth, with elastic band 
(Konig). 
The operation for cleft of the soft palate is done in the following 
way : The child is anaesthetized, placed in the hanging-head position— 
i. e. with the body on the table and the head hanging over the edge : 
this position is the best for the purpose of preventing the passage of 
blood into the trachea; the teeth are held apart by a Whitehead gag; 
the corners of the mouth held apart with elastic retractors. The edges 
of the cleft are freshened by a narrow-bladed knife in such a way as to 
make a broad surface, more tissue being removed from the mouth side 
than from the nasal or pharynx side. The edges of the cleft are brought 
together bv means of silver wire, silk, or silkworm-gut sutures, placed 
accurately and closely together, and lastly a myotomy of the tensor palati, 
and if need be of the palato-glossus and pharyngeus, is made with a teno- 
tome—if there be much tension ; dividing the tissue of the soft palate 
from the centre of each horizontal plate of the palate bone downward 
and outward to almost the free edge of the soft palate. In case no 
tension exists, this myotomy can be omitted ; the stitches are allowed to 
remain eight or ten days. In many cases the entire line of approxima- 
tion wall be found to have united ; in others, however, failure at one or 
more points may occur, necessitating a second operation, or, when the CONGENITAL DEFECTS. 
315 
defect is slight, it may heal by granulation or be assisted by touching with 
silver-nitrate stick or fine platinum cautery. The operation for closure 
Fig. 139. 
Staphylorrhaphy, sutures placed (Konig). 
of the hard palate—uranoplasty—requires anaesthesia, hanging-head posi- 
tion, Whitehead’s mouth-gag, and retractors, the same as staphylorrhaphy. 
The margins of the cleft are freshened as in closure of soft-palate 
defect. An incision is then made through the mucous membrane and 
periosteum close to the alveolar processes and 
parallel with the cleft; the periosteum is ele- 
vated from the bone; and the flap, consisting 
of mucous membrane and periosteum, is widely 
freed, so that the edges of the cleft can be ap- 
proximated without tension. The approxi- 
mation should be accurate, and the sutures 
employed should be silver wire or silkworm 
gut. Silk, however, can be employed, or even 
catgut, the latter, of course, having the ad- 
vantage of not requiring removal, but it is 
not thoroughly reliable. The sutures can be 
placed by means of a fine full-curved needle 
and needle-holder. The defect on the bone is 
covered by granulation, and the periosteum in 
the flap usually produces bone, closing the 
cleft eventually with bone-tissue. ( Vide also Appendix to this chapter.) 
Fig. 140. 
Uranoplasty—showing incisions 
(Tillmanns). 
The after-treatment requires considerable attention ; a liquid diet is imperative. 
In some cases it is advisable to introduce a soft-rubber tube into the oesophagus 
and feed the patient in this way. The mouth should be kept as clean as possible 
by mild antiseptic mouth-washes of borax. The patient, if old enough, is cau- 
tioned not to speak or attempt to speak. The late after-treatment consists of a 
prolonged and diligent effort on the part of the patient, assisted by instruction, to 
correct the cleft-palate speech. Much can be accomplished by intelligent and per- 
sistent training in this direction, but still the peculiarity of speech is seldom fully 
overcome. 316 
SURGICAL DISEASES ANI) INJURIES OF THE MOUTH, ETC. 
The use of artificial obturators instead of operative procedures has 
much to recommend it. Work of this kind is largely in the hands of 
dental surgeons, who are more competent than the general surgeon to 
make and apply the rubber plates required. Acquired defects of either 
the hard or the soft palate can be corrected in the same way as con- 
genital ones. The time to undertake such operations is of course after 
the pathological processes producing such defects have ceased to be 
active. 
Syphilis is a common cause of palatal defects : in such cases operation 
should be delayed until some months after the disappearance of the last 
symptom of such disease, and after an active and prolonged course of 
iodides and mixed treatment. Traumatism is a rare cause of acquired 
palate defects, and in those cases the operative repair should be either 
immediate or after the complete wound healing, and all disappearance 
of wound infection has taken place. When acquired defects are too 
large to be closed by plastic operation, the artificial obturator should be 
employed. (Vide also Appendix to this chapter.) 
Acute Inflammatory Processes in the Mouth 
Acute inflammatory processes include catarrhal stomatitis, thrush, 
ulcerating stomatitis, noma, and the involvement of the mucous membrane 
of the mouth in the acute infectious 
diseases, as measles, diphtheria, scar- 
let fever, small-pox, etc.; these latter 
being discussed more properly in 
works on general medicine. 
Stomatitis catarrhalis is a sim- 
ple catarrhal condition resulting from 
irritation of the mucous membrane 
from mechanical, chemical, or myco- 
tic causes. It presents the symptoms 
of a desquamating catarrhal condi- 
tion. 
Its treatment should be the 
removal of the cause wherever pos- 
sible, as, when the condition depends 
on decayed and neglected teeth, the 
removal or filling and cleansing of 
the teeth and the use of some simple 
and non-irritating antiseptic wash, 
such as boric acid. 
Stomatitis ulcerosa may fol- 
low simple catarrhal stomatitis or 
thrush, or may follow a severe and protracted illness or the lowering of 
the vitality of the tissues of the mouth from poisoning by mercury, 
phosphorus, lead, and copper. The character of stomatitis ulcerosa will 
differ with its cause. Its treatment will be the removal of the cause 
wherever possible; general and local treatment for the condition are at 
times required, the general being directed to the improvement of the 
resisting powers of the individual, and the local, such as application of 
Fig. 141. 
Destruction of cheek, the result of cancrum 
oris (A. McL. Tiffany, Amer. Syst. of Dent., 
vol. iii.). ACUTE INFLAMMATORY PROCESSES IN THE MOUTH. 
317 
silver nitrate in stick or in strong solution to the ulcers, and the use of 
mild antiseptic month-washes. 
Noma is a pecnliar mycotic gangrene of the tissue of the cheek and 
jaws occurring in illy-nourished children, living, as a rule, under bad 
hygienic conditions, and usually during or after an attack of one of the 
infectious fevers. The probable pathology of the condition is that it 
is not a disease produced by a specific microbe, but that a greatly lowered 
vitality, such as follows the infectious fevers in children living under 
extremely bad hygienic conditions, may enable the normal microbe 
inhabitants of the mouth to invade the tissues of the cheek and jaws, 
and produce a rapidly-spreading gangrene, and later general septic 
infection. 
The disease is rare in America. The diagnosis does not present difficulties 
when the disease is well established: an early diagnosis is desirable, and should be 
followed by energetic local treatment, the destruction of the invaded tissue with 
nitric acid or actual cautery, and the use of continuous mild antiseptic dressings 
and washes; general treatment should be directed to the support and stimulation 
of the little patient by properly selected food and alcoholic stimulants. The prog- 
nosis is grave; the great majority of the patients die. Those who survive present 
the disfigurations due to loss of tissue and the resulting cicatricial contractions. 
Extensive plastic operations are required for correcting deformities resulting from 
noma—flaps being taken from the face or neck and turned into the defect in the 
cheek, the raw surface from which the flap is taken being closed by sutures or 
covered by skin-grafts. ( Vide Vol. I. Chapter Y.) 
Cracks and fissures of the lips are common, and are usually 
trivial. They may, however, persist for some time, and give rise to 
much discomfort and demand surgical interference. Usually, touching 
the surface with nitrate of silver will be followed by wound healing and 
cure. It may in rare cases be necessary to dissect out the fissure or 
crack and unite the incision by sutures. At times the question of diag- 
nosis between the long-persisting fissure and epithelioma may present 
itself. Such question is to be settled early bv removing the tissues 
around the fissure and submitting them to microscopical examination. 
Syphilis, both primary and secondary, occurs on the lip; the former is 
more common in women than in men. Tuberculosis and actinomy- 
cosis of the lips occur, but are not common. 
Epithelioma of the lower lip is a very common surgical lesion; the 
upper is seldom involved. It occurs with much greater frequency in 
men than in women. This difference is attributed largely to the use of 
tobacco. A good deal of evidence seems to support this theory, as 
tobacco is one of the chronic irritants, like soot and paraffin, that seem 
to play some part in the production or localization of carcinoma. The 
picture of epithelioma of the lower lip is so typical that when the stu- 
dent lias seen several cases the condition is readily recognized. The 
age of the patient is of value; the presence of induration, scab-forma- 
tion, ulceration, the length of time the lesion has existed, all aid in 
the diagnosis. Primary syphilis might be mistaken for carcinoma. 
Wherever a question exists as to diagnosis, resort to the microscope 
should be made. 
The treatment is that of carcinoma elsewhere—removal of neo- 
plasm and adjacent tissue widely, and where there is evidence of 
lymphatic-node involvement these structures should be as widely as 318 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
possible removed. In epithelioma of the lower lip the submaxillary 
and sublingual salivary glands are often involved, and when involved 
should be removed. 
The prognosis of carcinoma of the lip is that of carcinoma else- 
where. When the lesion is limited to the tissues first involved, and 
Fig. 142. 
Cheiloplastic operation on lower lip (Tillmanns) 
there is no regional or general infection, it is possible to obtain a per- 
manent cure by complete removal of the diseased tissue; but whenever 
the nearest group of lymphatic nodes are involved, even microscopically, 
recurrence after removal, or rather a continuation of growth of the car- 
cinoma cells remaining, goes on unchecked by the operation. 
There has been a persistent effort made within the last few years by surgeons 
in various specialties to improve the prognosis in carcinoma, and this has led to 
the publication of conflicting statistics, some surgeons claiming as high as 25 or 
30 per cent, of permanent cures, or rather cases which have had no recurrence for 
three years after the operation. Most of these very favorable statistics are the 
result of juggling, the reporters being dishonest, at least with themselves. Perma- 
nent cure after operation for carcinoma is not common, and such cures at present, 
at least, form but a small percentage of our cases, probably 10 per cent., and are to 
be looked for, not in the extensive operations demanding wide removal and removal 
of adjoining lymphatics, but in the early simple cases where a V-shaped incision 
of the lower lip will remove all the carcinomatous tissue (Fig. 142). 
Benign tumors of the lower lip include naevi, cysts, dermoid and 
labial-gland cysts, and papillomatous and horny growths. 
Wounds of the lip are not rare. The tissue has high vitality and 
repairs itself readily. Accurate approximation should be obtained and 
efforts at antisepsis carried out. 
Macrocheilia is a condition where the lips are so thick as to pre- 
sent a deformity. The condition is sometimes extreme, and demands 
surgical interference and operation of removing a V-shaped mass as in 
excision of carcinoma, or an elliptical-shaped section of mucous mem- 
brane when the lips are much everted. 
The Tongue. 
The tongue is the essential organ of taste. It also assists in the functions of 
speech, mastication, and deglutition. It is composed of a number of muscles, 
extrinsic and intrinsic, and covered in part by mucous membrane of a peculiar 
character provided with papillae, circumvallate, fungiform, and filiform, and sup- 
plied with the terminal organs of taste, the taste-bulbs. By means of the extrinsic 
muscles the tongue is attached to the lower jaw, the hyoid bone, the styloid pro- THE TONGUE. 
319 
cess, and the soft palate. A median raphe of fibrous tissue divides the tongue 
into two halves. The raphe is comparatively non-vascular, and is a line in which 
incision can be made with little hemorrhage. The tongue is held forward in the 
mouth by the attachment of the mylo-hyoid, genio-hvoid, and hyoglossus muscles. 
When these muscles are divided in an operation, it may fall backward against the 
epiglottis and close the opening of the respiratory tract and produce suffocation. 
The nerve-supply of the tongue is derived from four nerves—the chorda tympani to 
the lingualis muscle, the hypoglossal nerve to the remainder of the muscles. The 
lingual branch of the fifth is the nerve of common sensation, and the glosso- 
pharyngeal the special nerve of taste. The arterial supply is derived from the 
lingual, facial, and ascending pharyngeal. The lymphatics drain into one or 
several nodes in the submaxillary region between the hyoid bone and tip of the 
chin, and into the deep lymphatic nodes of the neck. 
The tongue is developed in the foetus from the floor of the pharynx, 
and appears at first in three parts, a central and two lateral portions. 
The first is derived from the tissues between the first and second 
branchial arches in the mid-line. Immediately behind this the central 
portion of the thyroid is developed from a bud of hypoblastic tissue. 
The point from which this bud springs remains as the foramen caecum 
and as an abnormality. A duct may persist from the foramen caecum 
to the thyroid isthmus, called the thyroglossal duct. The lateral 
halves of the tongue are derived from the second and third branchial 
arches; the central part of the tongue is represented in the adult by 
the anterior portion, including the V-shaped line of the circumvallate 
papillae. 
Congenital malformations of the tongue present themselves most 
commonly as a very much shortened fromum, tongue-tie, or a growing 
together of the floor of the mouth and under surface of the tongue. 
The condition of tongue-tie seldom needs surgical interference, al- 
though the fraenum is often divided unnecessarily by physicians in 
children who are backward in learning to talk. Sometimes, however, 
the fraenum is so short as to interfere with the functions of the tongue 
and demands division. The operation is a simple one, and consists of 
division of the fraenum with curved scissors, care being taken to avoid 
injury to the ranine arteries, which run parallel to the fraenum on 
either side, covered simply by the mucous membrane. Another malfor- 
mation is a very long fraenum, permitting the tongue to fall backward 
against the epiglottis. Cases of sutfocation in children have been 
reported from this cause. A rare malformation is that of bifid tongue. 
An abnormally large or long tongue or abnormally small tongue, or 
even total absence of the tongue, occurs as a congenital defect. 
Injuries of the tongue may result from mechanical, chemical, or 
thermic causes. 
The mechanical injuries present themselves as incised, lacerated, and 
penetrating wounds. Lacerated wounds occur often from biting the 
tongue in epileptic attacks—from falls upon the face with some foreign 
body, as a pipe, in the mouth. Wounds of the tongue may be serious 
from division of some large arterial branch, and may require ligation 
of the vessels at the site of injury, or ligation of the lingual artery at 
the point of election immediately above the hyoid bone. Extensive 
wounds of the tongue should be handled as wounds elsewhere : the 
hemorrhage should be controlled, the tissue made as aseptic as possible, 
and the edges accurately united with catgut stitches. 320 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
The after-treatment should consist of mild antiseptic mouth-washes. The fact 
that local infection may extend to the tissue of the floor of the mouth, and even 
to the pharynx and larynx, the latter sometimes resulting in cedema of the larynx 
and demanding tracheotomy, should be borne in mind. 
Chemical injuries of the tongue may result from the drinking of 
acids and alkalies. The treatment required has been outlined in 
similar injuries of the mucous membrane of the mouth. Burns result 
from the accidental drinking of very hot liquids; as a rule, they are 
not severe and require as treatment a mild antiseptic mouth-wash. 
Acute inflammatory lesions include acute inflammation of the 
mucous membrane and acute inflammation of the deeper tissues of the 
tongue and the floor of the mouth. Acute inflammations of the mucous 
membrane are usually coexistent with stomatitis, and due to the same 
causes and require the same treatment. 
Acute inflammation of the deeper tissues of the tongue, acute paren- 
chymatous glossitis, may result from injury or be secondary to some 
lesion of the mucous membrane, or it may appear without the occurrence 
of a recognized injury. It may be limited to one side of the tongue. 
Usually, however, it involves both lateral halves. 
The symptoms are those of swelling, sometimes extensive ; pain and 
dryness of the surface; and constitutional symptoms varying in degree, 
but often marked; the inflammation may extend to the floor of the 
mouth and to the epiglottis and larynx ; suppuration may result; when 
pus forms it should be early recognized and evacuated by free incision. 
In making the incision care should be taken to avoid the large vessels, and if 
the pus-accumulation is deep, the best plan to pursue is that adopted by Hilton 
in deep cervical abscess—i. e. the division of the mucous membrane with the 
scalpel, and then bore into the deeper tissues with a closed artery-forceps until 
the pus-cavity is reached. The blades of the forceps are then opened and with- 
drawn in this position, making in this way free drainage with the least possible 
danger to the vessels and nerves of the part. 
When the inflammatory process has extended to the floor of the 
mouth it may result in the condition described bv Ludwig, and known 
as Ludwig’s angina. This condition may result from an acute glossitis, 
but is more commonly the result of infection extending from the teeth or 
jaw, or may make its appearance as a primary condition without any 
other known injury or pathological condition. It is an acute inflamma- 
tory affection of the tissues of the floor of the mouth, involving especi- 
ally the fibrous tissue. It may or may not go on to suppuration ; the 
dangers are general infection and oedema of larynx. 
Early in these cases the treatment should be hot aseptic poultices 
externally and antiseptic mouth-washes. 
If the infiltration is extreme, free incision, both externally and internally, is 
required, after the Hilton method, and if pus-formation occurs free drainage in 
the same way. The danger of cedema of the larynx may usually in this way be 
avoided, but if urgent dyspnoea presents itself, a tracheotomy should be prepared 
for and not too long delayed. The oedema of the larynx may come on rapidly. 
The author has seen one case in which this condition came on and resulted fatally 
within a few hours after the first symptoms presented themselves. 
Chronic injuries of the tongue require mention. These are com- 
monly the result of irritation of ragged and diseased teeth. They pre- 
sent themselves as chronically inflamed points of cicatricial and granular THE TONGUE. 
321 
tion tissue. They are cured usually by the removal of the cause; some- 
times, however, they may form the starting-point of carcinoma. Con- 
siderable clinical evidence goes to support the statement that carcinoma 
of the tongue may result from chronic irritation and chronic injuries to 
its mucous membrane. 
Granulomata of the tongue include tuberculosis, syphilis, and 
actinomycosis. Tuberculosis of the tongue as a primary affection is 
rare. It occurs usually in cases of general tuberculosis. 
When primary the diagnosis is difficult, and the case may be mistaken 
for carcinoma or syphilis. Sometimes the bacilli of tuberculosis can be 
found in the scrapings of the ulcer, but this is not the rule. Syphilis 
can be eliminated by the use of large doses of iodide. The lesion 
appears, as a rule, as a chronic ulcer with mouse-gnawed edges and 
covered with a gray membrane. The question of diagnosis between 
carcinoma and tuberculosis is often difficult. The peculiar mouse- 
gnawed edges of the ulcer, the fact that the margins are not as indurated 
as in carcinoma, the presence of small tubercles in the immediate 
vicinity of the lesion, and the removal of a small section and its histo- 
logical examination will, as a rule, determine the diagnosis. In cases 
of advanced general tuberculosis, tongue-tuberculosis should receive 
palliative treatment, the occasional application of silver nitrate, the use 
of an antiseptic mouth-wash. In cases of primary tongue-tuberculosis 
very radical treatment should be employed—the removal of the entire 
lesion and the healthy tissues some distance beyond, either with knife 
or cautery. 
The prognosis in such cases, not only for the cure of the local 
lesion, but the prevention of general infection, is good. 
Caseating tubercular foci may appear in the tongue as in the mam- 
mary gland—may be single or multiple. Their treatment, when 
simply an evidence of general tuberculosis, should be palliative or 
incision and removal of tubercular granulation-tissue with sharp spoon ; 
when primary, wide and radical removal. 
Syphilis of the tongue is common. It may present itself in several 
forms, either the primary lesion of syphilis or the mucous patches of 
secondary syphilis or gumma, which may break down and form a deep 
syphilitic ulcer; or, lastly, syphilitic warts of the tongue. 
The primary lesion of syphilis is not common ; it is not often diagnosed early 
because of its occurrence in such an unusual locality. It presents the character- 
istics of hard chancre, usually single, indurated base, sloping edges, slight dis- 
charge, resulting adenitis. In questionable cases treatment should be delayed 
until the diagnosis is made certain by the appearance of secondary symptoms. 
The other forms of syphilis are, as a rule, readily recognized, and should be sub- 
mitted to antisyphilitic treatment of iodide of potash and mercury, and local 
treatment of silver nitrate and antiseptics; best, boric-acid mouth-washes. Syph- 
ilitic condylomata can be removed, but the general and local treatment as outlined 
above should be instituted. 
Actinomycosis of the tongue is a rare lesion. The condition may 
present itself as a hard mass of granulation tissue, or later, after soften- 
ing, as an ulcer or cold abscess. 
The diagnosis must depend on the discovery of the actinomyces 
from the gross appearance of the pus or by the microscope. 
The TREATMENT is the removal of the granuloma with sharp spoon, 322 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
knife, or cautery, and the internal administration of iodide of potash, 
which from recent clinical evidence seems to have a curative effect. 
The prognosis, when the lesion is not extensive, is favorable under 
such treatment. (See Yol. I. Chapter YIII.) 
The benign tumors of the tongue include ncevi, which are common, 
dermoid, lipoma, papilloma, fibroma, and enchondroma. In this connec- 
tion we may well discuss the matter of retention-cysts of the small mucous 
glands about the tongue and the rather confused subject of ranula. Ncevi 
of the tongue may be divided into arterial, venous, or capillary accord- 
ing to the preponderance of one or the other systems of blood-vessels 
involved. They are, as a rule, congenital, and often present themselves 
as very small tumors at birth, which may grow rapidly and involve a 
large portion of the tongue, and even extend beyond the limits of that 
organ. They are to be treated as nsevi elsewhere—when possible by 
clean excision; when not, ligation or the use of galvano-cautery needles. 
A condition somewhat resembling naevi is the condition of macro- 
glossia, which is due to an hypertrophy of the lymph-vessels. Cases 
of macroglossia grow sometimes to great 
size. (See Yol. I. Chapter XXX.) 
They demand operative relief, excision 
of the redundant portion, and accurate 
flap-formation, and suture to manufac- 
ture a tongue of the tissue allowed to 
remain. The other forms of benign 
tumor, dermoid cysts, lipoma, enchon- 
droma, fibroma, etc., are to be treated 
by removal. 
Retention-cysts of the tongue are 
common, those occurring in the floor of 
the mouth being grouped under the name 
ranula. The most common is a cyst 
formed by retention in the gland of 
Nuhn on the side of the frsenum. Simi- 
lar clinical pictures are presented by retention-cysts of the duct of 
Wharton or the ducts of Rivini. 
The diagnosis is, as a rule, not difficult, but may be mistaken for a 
dermoid in the floor of the mouth. Usually the cyst-wall is thin, trans- 
parent, and the cyst filled with clear fluid. 
The best treatment is to dissect out the entire cyst-wall, which 
can, as a rule, be done. When this is not possible, a large section of 
the cyst-wall should be snipped out with scissors and the cavity packed 
with gauze, and a permanent opening obtained, or the cyst-wall remain- 
ing can be destroyed bv the cautery. Dermoid cysts in the floor of the 
mouth, when small and superficial, should be dissected out by an intra- 
oral operation; when large and deeply seated, an external dissection is 
to be preferred. 
The tongue is often the seat of primary epithelioma. The lesion 
occurs much more frequently in men than in women, and, like carci- 
noma elsewhere, is a disease of advanced middle life and old age. It is 
probable that the use of tobacco is an etiological factor in the develop- 
ment of tongue-carcinoma : cicatricial tissue, the result of chronic lesions 
Fig. 143. 
Macroglossia (Tillmanns). THE TONGUE. 
323 
and benign growths, such as papilloma, sometimes becomes the seat of 
carcinoma. The cancerous growth begins, as a rule, on the tip or sides 
of the tongue, and consists in the majority of cases of Hat epithelial 
cells. It rarely begins in the epithelium of the glands of the tongue. 
The diagnosis is made from the induration, the chronicity of the 
lesion, the age of the patient, and by the exclusion of the granulomatous 
lesions, of syphilis, tuberculosis, and actinomycosis. The disease may 
appear as a warty growth, an ulcer, or as a fissure. In all forms the 
characteristic hardness of carcinoma is present. 
In advanced cases the diagnosis is easily made from the clinical picture. In 
lesions seen early it may be impossible from the clinical evidence above to make a 
diagnosis. In such cases syphilis should be excluded by antisyphilitic treatment, 
and the question of the pathology of the process established before radical ope- 
ration by a removal of a part of the growth, and a careful histological examina- 
tion. An early and accurate diagnosis is of the greatest importance. Every warty 
growth or persistent ulcer or fissure of the tongue, especially in individuals beyond 
forty, should be regarded with suspicion, and its benignant or malignant character 
determined by the most careful analysis of the case, resort being made to the 
removal and microscopical examination of the tissue where a positive diagnosis can- 
not be arrived at by other means. A primary carcinoma of the tongue is followed 
later by regional involvement of the submaxillary lymphatic nodes and cervical 
lymphatics—by the involvement of the surrounding structures, the submaxillary 
gland, the sublingual gland, the tissues at the floor of the mouth, the fauces, and 
even the inferior maxilla. In advanced cases the condition of the patient is most 
pitiable: severe pain, interference with speech, mastication, and deglutition, pro- 
found carcinomatous cachexia, gradual exhaustion, septic infection, hemorrhage, 
complete the clinical picture. 
The prognosis is grave, both from the standpoint of possibility of 
cure and the life-expectancy of the individual. Cases live from one to 
two years after the beginning of the disease. Return after even early 
and radical operations is the rule; probably not 10 per cent, of cases of 
carcinoma of the tongue are alive and free from recurrence three years 
after radical operation. 
The TREATMENT of carcinoma of the tongue is simply stated: 
early and radical removal in operable cases; the euthanasia of morphine 
and cleansing mouth-washes are advisable in the inoperable cases, with 
possibly the added resection of the lingual nerve to relieve the excruci- 
ating pain which is an almost constant accompaniment; and proximal 
ligation of the lingual artery to control hemorrhage and to retard the 
rapidity of the growth. The operative treatment involves either the 
partial or complete removal of the tongue and draining lymph-nodes. 
In small lesions removal of the involved area and the apparently normal 
tissue wide of the disease should be the treatment. In lesions distinctly 
limited to one side, all of that side should be removed. In advanced 
cases and cases involving both sides the operation of complete extirpa- 
tion of the tongue and adjoining lymphatics should be carried out. 
Partial excision of the tongue can be, and should be, made as an 
intraoral operation ; a preliminary ligation of the lingual just above the 
hyoid bone can be made, but is usually not necessary. The mouth is 
thoroughly cleansed and made as aseptic as possible. The patient is 
anaesthetized; a mouth-gag is inserted between the teeth and widely 
opened; the tongue is drawn well out of the mouth with a stout silk 
suture passed through the tips or with volsellum forceps. If the lesion 
involves the tip, after division of the frsenum a V-shaped segment, in- 324 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
eluding the carcinoma, is removed, the hemorrhage controlled by catgut 
ligatures, and the lines of incision approximated by sutures. 
When the carcinoma is limited to one-half of the tongue, after division of the 
frsenum the tongue is split into two halves with scissors through the comparatively 
non-vascular raphe. The diseased half is removed with scissors, the hemorrhage 
controlled with clamp-forceps, the larger vessels are ligated, and the parenchyma- 
tous oozing is controlled by the deeply applied sutures employed to approximate 
the mucous membrane. The same result may be obtained by removal with gal- 
vano-cautery wire or ecraseur. Clean removal with scissors and careful ligation is 
to be preferred to either 6craseur or cautery. Complete extirpation of the tongue 
should be made through the floor of the mouth as an external operation, after the 
method of Kocher, of Regnoli, or of Billroth. 
Kocher’s Operation.—An incision is made from the symphysis of the 
jaw downward in the median line to the body of the hyoid, then along 
the body and great cornu of the hyoid, and then from the tip of the 
great cornu to the mastoid process. This flap is dissected upward, the 
facial vein and artery ligated. The submaxillary gland is either turned 
upward with the flap or removed. All lymphatic nodes are extirpated. 
The mylo-hyoid muscle is separated from its attachment to the inferior 
maxilla, the mucous membrane of the mouth divided, and the tongue 
drawn out through the incision. The entire organ is then under direct 
control, and can be either completely or partially removed. If the 
entire tongue is to be removed, the lingual artery of the opposite side is 
ligated before the division of the lingual mass. A preliminary trache- 
otomy is desirable in cases of extensive involvement, but is not always 
necessary. After the introduction of the tracheotomy-tube the pharynx 
is tamponed with sponge or gauze to which a strong silk ligature is 
attached to facilitate its removal. The tongue can be removed either 
by cautery, 6craseur, or scissors. The latter is to be preferred, great 
care being taken to ligate each bleeding point. The wound is packed 
with iodoform gauze ; the tracheotomy-tube 
may be removed at once or allowed to 
remain a number of days. The patient is 
fed with a stomach-tube; the external 
wound is not closed, but allowed to heal by 
granulation. The dangers of the operation 
are hemorrhage, sepsis, and aspiration pneu- 
monia. The mortality to be looked for in 
uncomplicated cases of extirpation of tongue 
is about 5 per cent. Kocher’s own cases 
included a number of complicated cases 
which resulted in 20 deaths in 104 opera- 
tions. 
The operation of Kocher’s is to be pre- 
ferred to the other external operations of 
Regnoli, Billroth, v. Langenbeck, and 
Sedillot, which, however, are of sufficient 
interest and value to warrant a brief description. 
Fig. 144. 
Lines of incision for total excision 
of the tongue (Chalot). 
The Billroth operation consists of a transverse incision below the symphysis, 
joined by two incisions, one on either side and parallel to the body of the jaw, 
extending to the great cornu of the hyoid bone. The skin and superficial fascia 
are first divided ; then the mylo-hvoid, the genio-hyoid, and the genio-hyoglossus 
muscles are separated from their attachment to the lower jaw; the mucous mem- JAWS AND TEETH. 
325 
brane at the floor of the mouth is divided, and the tongue drawn through the 
external incision and the extirpation proceeded with. 
The Regnoli operation, of which Billroth's operation is a modification and 
improvement, consists of practically the same procedure by a different external 
incision. An excision is made in the middle line extending from the symphysis 
to the body of the hyoid bone. This is joined by two lateral incisions extending 
from the symphysis parallel with the lower jaw to the attachment of the masseter 
muscle. 
The operations of SMillot and v. Langenbeck involve the division of the lower 
jaw, an undesirable complication. Such a procedure maybe required in extensive 
operative removal of the tongue and contiguous structures, such as the fauces and 
tonsil, but, as a rule, the same result can be accomplished by the Kocher operation. 
The cases of carcinoma of the tongue and contiguous structures which 
come to the surgeon late in their history with extensive involvement, 
both regional and general, form a group which should be classed as 
inoperable cases and which should be carefully studied. The results of 
radical operations for tongue carcinoma are not sufficiently encouraging 
to warrant the surgeon in urging an operation in extensive cases of long 
standing, nor to hold out to the patient great hopes of a permanent cure. 
There can be no doubt but that many cases are operated upon where it 
is clearly impossible to remove all of the diseased tissue, and where it 
must be evident to the experienced surgeon that the cases have passed 
beyond the possibility of cure : we should recognize these cases as being 
Fig. 145. 
inoperable, and discourage and refuse to perform any operation unless it 
be the palliative ligation of the lingual artery. 
The treatment here must be, as already stated, morphine in large 
and increasing doses ; deodorizing and aseptic mouth-washes ; attention 
to the general condition and comfort of the patient. 
Exposure of base of tongue by incision along border of the jaw (Tillmanns). 
Jaws and Teeth. 
Each jaw presents an alveolar process which at birth contains the temporary 
and permanent teeth, the enamel portion of which is derived from the buccal epi- 
blast, the remainder from the mesoblastic tissues of the mandibular and maxillary 
arches. After the loss of the teeth the alveolar processes are absorbed. The lower 
jaw contains the inferior dental canal, which has passing through it the inferior 326 
SURGICAL DISEASES AND INJURIES OE THE MOUTH, ETC. 
dental nerve and vessels. The upper jaw contains the cavity of the antrum and 
the vessels and nerves of the upper teeth. The development of the teeth is of 
interest. Its careful study will explain such conditions as odontoma, abnormal 
position of teeth, the unusual occurrence of more than two sets of teeth, etc. The 
teeth consist of a crown of enamel, a body of dentine, and a coating of the dentine 
or the fang by a structure called cement. Between the body and crown is a con- 
stricted portion called the neck of the tooth. In the centre of the tooth is the pulp- 
cavity, filled by the pulp-tissue and communicating with the dental vessels and 
nerves through the small canal in the fang. 
Congenital Malformations of the Jaws and Teeth.—The com- 
mon malformation of the upper jaw called cleft palate has been dis- 
cussed in connection with the surgery of the mouth; other rare malfor- 
mations are arrest of development of one side of the upper or lower jaw 
or failure of union of the two halves of the lower jaw. Such conditions 
are not amenable to surgical treatment. Malformations of the teeth are 
common. They present themselves as excessive development of a tooth 
or a part of a tooth, either the enamel or the fang, or lack of develop- 
ment of a single tooth. An amalgamation of two or more teeth into a 
single mass; the development of a tooth in an abnormal position, as in 
the tissues of the hard palate; the projection of a tooth in an abnormal 
direction; the absence of a number of teeth—this condition may exist 
as a total absence, edentulous jaws 
resulting; the presence of an ex- 
cessive number of teeth, three sets 
of teeth having been often re- 
ported, but few of these cases 
are credited. The formation of 
a tooth-tumor, an odontoma, from 
the embryonic tooth-tissue is to be 
regarded as a congenital abnor- 
mality. Most of these malforma- 
tions are treated by dental sur- 
geons ; the general surgeon, how- 
ever, should be familiar with such 
conditions, because some of tooth- 
malformations present themselves 
as obscure conditions in patients 
applying for diagnosis and treat- 
ment. A tooth which has failed 
to erupt may lie as an encapsulated foreign body for years, and then 
become the focus for infection and abscess and resulting sinus, or, sur- 
rounded by granulation-tissue, may be mistaken for malignant growth. 
Injuries of the Jaws and Teeth.—Fractures and dislocations of the 
jaws have been discussed in Volume I. under the general subject of Frac- 
tures and Dislocations. Injuries of the teeth, including fractures, the 
complete separation of the teeth from the alveolar process, and the subject 
of reimplanting such teeth, belong not to general, but to dental, surgery. 
Diseases of the teeth and alveolar processes and gums include 
a discussion of dental caries, resulting pulpitis, infection of nerve-canals, 
and alveolar abscess. 
The subject of dental caries has been much discussed, and many 
theories have been advanced to explain the condition. It was not until 
Fig. 146. 
Misplaced and imprisoned tooth (Forget), JAWS AND TEETH. 
327 
the recent development of modern bacteriology had thrown light upon 
it that a rational explanation of dental caries was found. 
The accepted view to-day is as follows: Many bacteria of the mouth have the 
power of producing lactic acid. Lactic acid dissolves out the inorganic elements 
of a tooth; it has little effect upon normal enamel, but acts rapidly upon dentine. 
A crack in the enamel and congenital defects in the enamel favor this process. 
After a decalcification has been brought about, the organic tissue remaining is 
readily destroyed by the saprophytic bacteria of the mouth. This destruction may 
extend to the pulp-cavity; as soon as the pulp-cavity is uncovered it becomes 
infected and sooner or later is destroyed. The infection may travel down a nerve- 
canal and infect the tissue of the alveolar process and gums, the periosteum, or the 
jaw itself. As a rule, the infection is limited, forming a small alveolar abscess or 
gum-boil, but the infection may be extensive and even result in general septicaemia, 
pyaemia, or death. A common result of alveolar abscess is a sinus leading from 
the root of the tooth through the alveolar process and opening on the mucous 
membrane. 
The treatment of dental caries is the removal of the carious structure and 
the filling of the cavity with gold, cement, or amalgam. This treatment is very 
satisfactory, and has been developed by American dentists to a high degree of 
technical perfection. When infection of the pulp-cavity has occurred, the tooth 
can be saved by a destruction of the pulp with arsenic or other chemical agents, 
the removal of the pulp, the thorough sterilization of the pulp-cavity and nerve- 
canal, and filling the cavity with gold or amalgam. It is, however, difficult to 
thoroughly disinfect the pulp-cavity and nerve-canal, and as a result many of the 
teeth in which the nerve has been killed have a small suppurating sinus leading 
from the root to the mucous membrane. 
Alveolar abscesses, if small and superficial, usually open without 
assistance from the surgeon. When deeply seated they are exceedingly 
painful, the pain being produced by the retained 
inflammatory secretions. The pus burrows 
through the alveolar process; as soon as the 
diagnosis of alveolar abscess is made, the tooth, 
if worthless, should be extracted. This affords 
free drainage and immediate relief. If it is not 
desirable to extract the tooth, an early incision 
should be made and free drainage for the in- 
flammatory products obtained. When a large 
alveolar abscess forms and points toward the 
integument, even though fluctuation can be 
clearly made out from external palpation, still 
the abscess should always be incised within the 
mouth-cavity in order to avoid the disfiguring 
and retracted scars which often result where 
the abscess opens on the face. 
Gingivitis, or inflammation of the gums, 
may result from a number of causes, local and 
constitutional. Pyorrhoea alveolaris, mercu- 
rial gingivitis, scorbutic gingivitis, lead gingi- 
vitis, and phosphorus gingivitis are known. 
When the disease is due to purely local causes, 
as tartar on the teeth arid uncleanliness, the 
cure can be brought about by the removal of 
the cause. When mercury is the cause, the 
treatment would demand a discontinuance of 
the drug, and locally mild antiseptic mouth-washes. In cases of 
Fig. 147. 
Chronic alveolar abscess at the 
root of a lower incisor: a, 
abscess-cavity in the bone; 
b, fistula discharging on the 
gum; c, lip; d, tooth (G. V. 
Black, M. 1)., Amer. Syst. of 
Dent., vol. i.). 328 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
scurvy and lead-poisoning the cause should be removed and proper 
general treatment and locally mild antiseptic washes should be advo- 
cated. 
Extraction of the teeth is to-day not considered a part of general 
surgery, but a knowledge of a few general principles may prove of value. 
The operation has been already described in Vol. I. Chapter XVIII. 
Usually in these operations an anaesthetic is not required; gas is to be preferred 
to chloroform or ether when general anaesthesia is necessary. Local anaesthesia 
with cocaine is not to be employed, because the anaesthetic effect is not very marked, 
and because of the danger of cocaine-poisoning and the possibility of infecting the 
tissues by the introduction through the gum-tissue of the needle, which cannot 
be effectually sterilized. The author has seen one case of death following local 
anaesthesia from cocaine injections, the death being caused by infection and pyae- 
mia ; and a number of serious cases of poisoning from cocaine itself are reported 
from its use in teeth-extraction operations. The dangers of the operation are 
slight, and yet jaw fractures and serious infection occur in a small percentage of 
cases. The hemorrhage is, as a rule, trifling, but in cases of haemophilia and 
leukaemia it may be serious or even fatal. In cases of serious hemorrhage in these 
conditions pressure is the best means of controlling the bleeding. In some cases 
an aseptic gauze packing will control the hemorrhage; in others digital pressure, 
with relays of assistants, may be required. The author has seen one case of haemo- 
philia in which it was necessary to keep up digital pressure almost continuously 
for several days before the bleeding ceased. 
The after-treatment of tooth extraction should be the use of a mild aseptic 
mouth-wash. Unfortunately, this is often omitted. The importance of aseptic sur- 
gery has been recognized rather later by dental surgeons than by the general surgeon, 
and has not been as generally adopted. It is true that it is impossible to completely 
sterilize the mouth-cavity, but the dangers of infection can be reduced materially 
by vigorous attempts to make the field of operation clean with antiseptics. 
Acute inflammatory processes of the jaws include periostitis and 
osteomyelitis, and resulting necrosis. The most common cause of such 
lesions is infection of the alveolar process from a carious tooth or from 
fracture. Osteomyelitis of the jaws may occur as a primary condition 
from infection from the circulation, as occurs in osteomyelitis of the 
tibia, but this form is rare. Osteomyelitis sometimes follows the acute 
infectious diseases, as scarlet fever, small-pox, typhoid fever, measles, 
etc. (See Chapter XIV. Vol. I.) Other causes are mercurial poisoning 
and phosphorus-poisoning. The alveolar process is alone involved, as a 
rule, in pus-infection from a tooth caries ; sometimes, however, the entire 
thickness of the jaw may become involved. 
The treatment is free and early incision to afford drainage for the 
inflammatory products, and later, if necrosis results, sequestrotomy. 
The periosteum should be preserved when possible, for in the history of 
these cases, even when the entire thickness of the jaw is removed, a 
serviceable jaw is reproduced from the periosteum remaining. 
Necrosis from mercurial and phosphorus-poisoning is now, fortunately, rare, 
because of the smaller doses and less frequent use of mercury as a drug, and because 
the improved methods of manufacturing matches, at least in America, protects the 
employes better from the phosphorus fumes, and the weekly examinations of the 
mouths of match-workers now in vogue in American match-factories reveals the 
condition in its incipiency, so that the patient is saved from serious phosphorism, 
either by being compelled to give up his employment or by proper hygiene of his 
mouth. The pathology of phosphorus-necrosis is of interest. Chronic phos- 
phorus-poisoning produces an ossificating periostitis ; small osteophytes form in the 
periosteum of the alveolar process. This condition so lowers the vitality of the 
jaw-tissues, gums, periosteum, and bone that the normal bacteria of the mouth 
can invade the tissue and produce infection. JAWS AND TEETH. 
329 
Dr. S. D. Stewart of Akron, Ohio, a dental surgeon of large experience in 
handling the employes of a match-factory where for a number of years lie has 
made weekly examinations of the mouths of the employes, states that phosphorus- 
poisoning does not occur in individuals with good teeth who keep them clean with 
the daily use of a tooth-brush; further, that the removal of decayed teeth or the 
tilling of cavities, the removal of tartar, and perfect cleanliness, even in individuals 
who enter the employment of match-making with unhealthy mouths, will practi- 
cally ensure immunity against phosphorus-necrosis. 
Empyema of the Antrum.—As a secondary lesion resulting from 
inflammatory lesions of the teeth and bone structure of the upper jaw 
we And empyema of the antrum of Highmore. This condition may also 
be secondary to inflammatory lesions in the nasal cavity. 
The symptoms of empyema of the antrum are pain and swelling, 
discharge of pus, either through a fistula in the mouth or into the nasal 
cavity, where an exit for pus is present. When there is no exit the 
accumulation may distend the thin wall of the antrum and appear as a 
prominence in the mouth or on the face, or, by pushing up the floor of 
the orbit, produce a protrusion of the globe of the eye. 
When empyema of the antrum is due to diseased teeth or bone structure, these 
causes should be removed ; free drainage should be obtained, either through the 
mouth or nasal cavity. Where a diseased upper molar is the cause, after removal 
of the tooth a free opening may be found leading from the root-socket into the 
antrum, or, if a free opening does not exist, with a perforator the antrum may be 
opened and drained with a silver or rubber tube. The drainage may be made in 
the thin wall of the antrum just above the alveolar process, the thin bone being 
readily perforated at this point, or we may employ the method of Mikulicz of 
boring through the external wall of the nasal cavity below the inferior turbinated 
and making a permanent free opening between the nasal cavity and antrum. 
Park urges free opening into the antrum through its external thin wall, made from 
the mouth, so as to permit of digital exploration of its entire cavity. 
Syphilis, tuberculosis, and actinomycosis are the common granulornata 
affecting the jaws. Syphilis presents itself as a late secondary lesion in 
the form of syphilitic necrosis and caries, involving more commonly the 
upper jaw, especially the hard palate. 
The diagnosis is usually made from the history of the case, but 
here, as elsewhere, there may be an absence of history or the patient 
may deny having had syphilis. 
Energetic mixed treatment, and especially iodide of potash in 
large and increasing doses, two to three hundred grains a day, if neces- 
sary, should be employed; sequestra should be removed by operation. 
The treatment is, as a rule, highly satisfactory. The author has re- 
peatedly seen cases of syphilis of the jaws yield to large doses of iodide 
when small doses, 10—20 grains, have been given without apparent 
effect. 
Tuberculosis of the jaws is not common. It may be an accompaniment of 
general tuberculosis. When primary the local focus should be radically removed. 
The jaw is a favorite seat of that rare lesion actinomycosis, or at least, if not 
the bone itself, the soft parts in contact with the bone are involved. Its common 
occurrence at this point in cattle has given to the disease its popular name 
of lumpy jaw. (See Vol. I. Chapter IX.) The disease may be mistaken for 
sarcoma. When pus exists it sometimes contains the small yellow bodies charac- 
teristic of actinomycotic pus. The diagnosis is settled by a histological examin- 
ation of the tissue. The treatment is removal of the granulation-tissue and the 
internal use of iodide of potash. 
Diseases of the inferior maxillary articulation of surgical interest 330 
SURGICAL DISK ASKS ANI) INJURIES OF THE MOUTH, ETC. 
are especially those conditions followed by partial or complete ankylosis 
of the joint. These are acute conditions, such as acute arthritis following 
injury, infectious diseases, as typhoid fever, small-pox, etc., acute rheu- 
matism, gonorrhoeal rheumatism, etc., or inflammation extending from 
the teeth or jaws to the joints. The author has seen two cases of 
pseudo-ankylosis result from the irritation of the eruption of a wisdom 
tooth. Chronic lesions also, as arthritis deformans and tuberculosis, 
and lastly cicatricial contractions following burns, noma, and injuries, 
result later in ankylosis. The condition of complete ankylosis is one 
very difficult to rectify. In cases of pseudo-ankylosis, opening the 
jaws under anaesthesia, and later the daily use of a mouth-gag to pry 
the jaws apart either by the patient or the surgeon, may bring about a 
cure. In cases of complete ankylosis a false joint must be made by an 
excision of the condyloid and, when necessary, coronoid processes. 
When complete ankylosis is complicated with extensive cicatricial con- 
traction of the soft tissues, an extensive plastic operation is required. 
The results after operation for complete ankylosis are not, as a rule, 
satisfactory. 
A peculiar condition of relaxation of the temporo-maxillary ligaments is 
occasionally met with, which permits of frequent subluxation of the joint. This 
occurs with a snapping sound usually during eating—is unnoticed by the patient 
himself, but not by others. It is painless, harmless, and not amenable to treat- 
ment. 
Tumors of the jaws include osteoma, odontoma, fibroma, chondroma, 
sarcoma, carcinoma, mixed tumors, as fibro-nlyxoma, and cysts. The 
vague term epulis given to tumors springing from the alveolar pro- 
cesses, and usually fibroma or sarcoma, has nothing of value to warrant 
its retention in a scientific classification of jaw tumors, and should be 
discarded. 
The differential diagnosis between these various tumors must be 
made from the clinical history and clinical evidence, and when this is 
not sufficiently clear on the histological examination of a portion of the 
tissue, the important point to determine is the benign or malignant 
character of the growth, as upon this must be based the character of 
the operation employed for the removal of the tumor. One form of 
tumor of special interest and of rare occurrence is the odontoma or 
tooth-tumor. These tumors are the product of abnormal development 
of a tooth-bud; they may consist of all the structures of the tooth, as 
enamel, cement, and dentine, or may involve but one of these to almost 
the exclusion of the other elements. ( Vide Vol. I. Chapter XXVI.) 
These tumors are benign and demand simply the removal of the tumor- 
mass. Great care should therefore be taken not to mistake them for 
malignant growths and remove unnecessarily a large section of the jaw. 
Cysts of the jaw due to cystic tumor-formation from a tooth-follicle are 
called dentigerous cysts: they may grow to a large size and demand the 
removal or destruction of the entire cyst-wall. 
Resection of the Jaws. 
Resection of the lower jaw may be demanded for necrosis, for granu- 
lomata, as tuberculosis and actinomycosis, and for tumors. The excision RESECTION OF THE JAWS. 
331 
may be partial or complete—may demand the removal of one lateral half 
of the jaw or of the horseshoe-shaped body. The technique of remov- 
ing one half of the lower jaw is as follows: An incision is begun at the 
symphysis a little below the bone and carried along the lower border 
of the body to the angle, then upward along the posterior border of the 
ramus to the condyloid process. The facial artery and vein are ligated 
and divided in front of the masseter muscle. The attachments of the 
masseter are divided; the periosteum at the line of the symphysis is 
divided vertically and the jaw divided in the same line with a saw. 
The attachments of the mylo-hyoid andgenio-hyoid and genio-hyoglossus 
muscles to the inner surface of the jaw are separated, care being taken 
to control the hemorrhage as the operation proceeds. The attachment 
of the mucous membrane of the mouth to the gums is divided. The 
attachment of the external and internal pterygoid muscles, the division 
of the inferior dental nerve and vessels, the division of the temporal 
and buccinator, allow of a free exposure of the temporo-maxillary 
joints, the division of the ligaments, and the removal of the bone. 
Great care should be taken in working at the upper angle of the wound 
not to injure the facial nerve, the internal maxillary artery, and Sten- 
son’s duct. In resection of a portion of the lower jaw for necrosis care 
should be taken to preserve the periosteum. In resections for neoplasms 
this is not, as a rule, possible. 
Resection of the upper jaw is a more formidable operation. The 
hemorrhage is, as a rule, great, and in cases of complete resection and 
in extensive resections for tumors it is often advisable to make a pre- 
Fig. 148. 
Resection of superior maxilla (Farabeuf). 
liminary tracheotomy, tampon the pharynx, and continue the anaesthetic 
through the tracheotomy-tube in order to prevent the blood flowing back 
into the larynx. 332 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
The operation can be done in the hanging-head position or in the sit- 
ting position under mixed partial anaesthesia. In extensive operations 
preliminary tracheotomy and operation under complete anaesthesia is to 
be preferred. 
A great number of incisions have been devised for the operation of resection 
of the upper jaw. The operation know as the Fergusson operation is, as a rule, to 
be preferred. (See Fig. 148.) The upper lip is split in the middle; the excision 
is then continued along the margin of the anterior nares, the Aving of the nose, the 
lateral margin of the nose to beneath the inner angle of the eye, then along the 
lower margin of the orbit to its lower and external angle; this excision extends to 
the periosteum; the flap is dissected up from the bone and reflected dowmvard 
Fig. 149. 
and outward; all hemorrhage is checked. The superior maxilla is then separated 
from the other bones of the face, a chain saw or keyhole saw or a large pair of 
bone-forceps or chisel may be employed. The malar, which is composed of com- 
pact tissue, is best divided with a saw; the palate process can be divided with 
large bone-forceps; the nasal process of the superior maxilla can be divided with 
forceps or chisel; the orbital process Avith chisel or bone-forceps ; the attachments 
of the bone behind to the palate bone and the attachment of the palate to the 
pterygoid process of the sphenoid are best separated by grasping the mass of bone 
after the separation above referred to has been completed in a large pair of bone- 
holding forceps and twisting out the entire mass. The hemorrhage is free, and 
should be controlled by pressure, forceps, and ligature. Great care should be taken 
to ligate every bleeding point. The Avound is packed with iodoform gauze and 
external incision closed. The dangers of the operation are sepsis and hemor- 
Resection of inferior maxilla (Farabeuf). EARLY OPERATIONS FOR THE CLOSURE OF CLEFT PALATE. 
333 
rhage and aspiration pneumonia. Many other methods of making the external 
incision have been employed : such as those of Velpeau and Langenbeck, but the 
operation of Fergusson is to be preferred. 
Partial resections are more often required than complete resections; 
removal of the alveolar process can be completed as an intraoral opera- 
tion by removal of the teeth, exposing the alveolar process with knife 
and periosteotom, and removal of the alveolar process with chisel or 
bone-forceps. Temporary resection is sometimes performed as an initial 
step in removing the second division of the fifth nerve or in the removal 
of a naso-pharyngeal tumor. 
In making an osteoplastic resection of the upper jaw the opera- 
tion of Langenbeck is to be preferred. A tongue-shaped flap of the soft 
parts and the bone between the hard palate and the floor of the orbit is 
raised and turned inward, the soft parts being allowed to remain attached 
to the bone after the operation, for which the preliminary osteoplastic 
operation is made, has been completed, the flap of bone and soft tissues 
is replaced and held in position by deep and skin sutures. 
APPENDIX. 
EARLY OPERATIONS FOR THE CLOSURE OF CLEFT 
PALATE. 
Truman W. Brophy, M. D., D. D. S. 
Operations for the closure of cleft palate should be performed in 
early infancy. In making this statement I fully realize that my views 
are not in accord with those of many distinguished surgeons, but clinical 
experience has demonstrated that what I presented to the profession a 
few years ago as a theory in regard to palate operations has become a 
well-established practice. It is well known that many infants which are 
born with this defect die within a short time after birth when the cleft 
is of a marked character. Tait says that one-half of the children born 
with extensive clefts die from starvation within a few days after birth. 
In this complication of hare-lip with cleft palate the practice has 
almost invariably been to operate upon the lip, and allow the fissure of 
the palate to remain unclosed. This, in my opinion, is a mistake. The 
palate should be first operated upon, for various reasons: 
1. The fissure of the lip enables the operator to gain a little more 
room in which to work. 
2. The closure of the palate is an operation attended with great diffi- 
culties in its performance; besides, the closure of the cleft through the 
alveolar process, if it exists, may be more surely accomplished when 
fully exposed to view through the divided lip than when covered as it 
would be subsequent to the closure of the lip. 
It is unnecessary to say that the bones are soft and will easily yield in early 
infancy. The tissues unite kindly, and the shock following the operation is not 
so great if performed within the first month as it would be later in childhood. It 
is a well-known fact that the nervous system of a child is not so well developed in 
early infancy as it is later; hence one of the advantages of performing this ope- 
ration before the nervous system has developed to a point which would subject the 
child to a more severe shock. The operation, therefore, should be performed as 334 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
soon as the functions of the organs of the body are well established. This may be 
within the first week or any time within the first month. 
3. After the operation the child will be better nourished. 
4. If performed in early infancy the muscles of the palate will 
be brought into action and will be developed, whereas if the mus- 
cles are not thus put into use they will atrophy, and later it will be 
found, as is often the case, that there is insufficient tissue to restore the 
palate to its normal form. It is scarcely necessary to state that muscu- 
lar tissue which is not subject to action and use will not develop nor- 
mally. 
5. One of the most important reasons why we should operate in early 
infancy is, that the parts operated upon early not only develop well, but 
the child when arriving at the age when articulation in the form of 
speech is attempted finds that he can speak as other children do, and 
does not acquire the habit of articulating through the nasal passage, 
which is characteristic of this deformity, for the nasal accent when once 
acquired cannot be easily corrected. Fissures or clefts of the palate are 
almost invariably accompanied with pharyngitis. 
6. Before the calcification of the bone is far advanced, and also 
before eruption of the teeth, the operation on the hard palate can be 
more easily and successfully accomplished ; if made subsequent to the 
eruption of the teeth, it is always attended with more difficulty and the 
results are less satisfactory. 
The operation is as follows: Introduce the oral speculum and vivify 
the edges of the fissure; do it thoroughly. A mere scraping of the 
mucous membrane will never suffice to bring about union which will 
be permanent and satisfactory. On the hard palate trim well the 
opposing surfaces of the bone. If this be well done, it will secure a 
sufficient exudate to make the operation a successful one in this respect. 
The knife will easily cut through the soft bone of the hard palate and 
the alveolar process of young patients. Then raise the cheek, and well 
back toward the posterior extremity of the hard palate, just back of the 
malar process, and high enough to escape all danger of not being above 
the palatal plate of the bone, insert a large braided silk suture, carrying 
it through the substance of the bone, so that it will come out at a cor- 
responding position upon the opposite side. It is often difficult to pass 
the suture through to the opposite side, and under such circumstances 
the needle, with eye in point, may be carried from the buccal surface of 
the bone to the median line, the stitch taken up with a tenaculum, and 
then the needle inserted from the opposite side, the thread then to be 
united and carried through. The silk suture is more easily introduced 
by the needle, but a wire suture of silver should be substituted for it 
and drawn through in its place, and this wire may be doubled in case 
the condition of the parts and the tension upon the tissues necessary to 
approximate them seem to require it. 
Nearer the front portion of the palate insert another wire, carrying 
it through the substance of the bone above the palatal plates, and out 
through the other side in a position corresponding to the place of 
entrance. Thus we shall have one wire passing over the palate in front 
of the malar process of the bone and another behind it. 
The next step is to take a lead button, moulded to fit the convexity 335 
EARLY OPERATIONS FOR THE CLOSURE OF CLEFT PALATE. 
of the part, and long enough to pass beyond the exit of the wire sutures, 
so that they will pass through it. Have it provided with eye-holes, 
through which are passed the protruded ends of the wires upon each 
side, and then twisted. These are heavy tension sutures, and once 
approximated the parts cannot be separated by the patient. If we are 
unable to close the fissure with these wires, if from lack of tissue or 
from firm resistance of the parts it cannot be done, there is a further 
method to be employed which will obviate these difficulties. After the 
cheek is well raised divide the mucous membrane just over the malar 
process. Here insert a knife in a horizontal direction, and when well 
inserted sweep the handle around from one side to the other, as from 
behind forward. In this way a maximum amount of bone is divided 
Fig. 150. 
Manner of placing sutures. No. 2 shows gain in closing defect after cutting malar process. 
and a minimum amount of the mucous membrane. This done on each 
side, the bone can very readily be moved toward the middle line. 
Having thus divided the bones upon either side, the wire sutures pass- 
ing through the lead buttons may again be twisted, and the cleft of the 
hard palate will be easily closed by approximation of the two sides. 
The incision in the mucous membrane in making the separation of the bones 
should be as small as possible, for the reason that this membrane must serve to 
retain the bones in proximity or to hold them nearly together. If, after the parts 
are approximated, they are kept antiseptically clean, the bones will kindly unite 
and the palate will be restored, so that its full function will be performed. 
Separation of the bones is attended with little hemorrhage, and the parts do not 
usually cause more inconvenience to the patient than the ordinary operation of 
lifting the hard palate according to the practice of Fergusson. 
The germs of the teeth are sometimes disturbed, as 1 have found 
later, when they were erupted, that certain teeth were imperfectly 336 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
formed. This applies to the molars of the temporary set, but the germs 
of the permanent teeth may also be disturbed, and the teeth made 
imperfect by this procedure; but the dental defects are of little import- 
ance when offset by the benefits of being relieved of so great a deformity. 
The palate, too, may be contracted to an abnormal extent; and yet it 
is a well-known fact that the alveolar process develops with the erup- 
tion of the teeth, and my experience has convinced me that in mouths 
thus treated the upper teeth when they erupt opposed in a normal way 
those of the lower jaw. If, however, the superior arch should be 
abnormally contracted, the means well known to the modern dentist 
may be employed to widen it. 
After the approximation of the edges in the manner I have described the parts 
should be thoroughly dried, the edges of the wound carefully examined, and if 
need be some fine sutures inserted here and there to ensure perfect coaptation of 
the parts. The after-treatment is very simple, consisting solely in antiseptic clean- 
liness, nourishing of the patient upon liquid food, the prevention of disturbance 
of the parts by the child, or of the introduction into the mouth of anything that 
might interfere with the sutures. Abrasions of the mucous membrane caused by 
the buttons need not disturb the operator, for they are usually slight. 
The difficulties attending the closure of the soft palate may be, to a 
very great extent, overcome by making use of the method which I 
A New Method of Closing the Soft Palate. 
Fig. 151. 
Staphylorrhaphy: sutures in position. 
here illustrate. Delicacy of the tissues and the tendency of the sutures 
to cut out suggested to me that a modification of the quill suture, long A NEW METHOD OF CLOSING THE SOFT PALATE. 
337 
ago introduced, would aid us materially in retaining the sutures and 
preventing their cutting out after performing the operation of 
staphylorrhaphy. 
Inasmuch as lead is tolerated so well by the tissues, I have employed 
it for this purpose. 
The first drawing (Fig. 151) will show cleft of the soft palate, the 
fissure extending through the palatal plates of the maxillary bones. 
After the edges of the cleft are well freshened, a properly formed 
needle, curved after the fashion of the gynecologist’s needle, is em- 
ployed with which to introduce silk sutures, four of which are carried 
through the tissues, as shown by the drawing, and these are substituted 
by rather strong silver sutures; then the lead plates are perforated with 
Fig. 152. 
Staphylorrhaphy : sutures and lead plates in position. 
holes corresponding to the number of four sutures, shaped so as to 
extend from the anterior margin of the fissure back to the distal border 
of the soft palate, and bent to conform to its shape. The wire sutures 
are then passed through the holes, as shown by the drawings, and 
twisted together. Tension is thereby exerted upon the divided portions 
of the palate and their edges are approximated. Should it become 
necessary, as is often the case, to divide the bones along the border of 
the hard palate nearest to the molar teeth, this may be done by the use 
of a strong scalpel or chisel, and then the lead plates are easily brought 
toward each other, together with the tissues that they embrace. In 
certain cases the elevation of the soft parts, together with the perios- 338 
SURGICAL DISEASES AND INJURIES OF THE MOUTH, ETC. 
teum, may serve our purpose quite as well : this can be accomplished 
by means of a properly bow-shaped periosteotome. After the edges of 
the plate have been approximated by the twisting the wire sutures to- 
gether, as shown by the drawing (Fig. 152), fine silk sutures may then 
be employed with which to hold the approximated edges in close contact 
and secure immediate union. 
The advantages claimed for this method of procedure are—1. The 
prevention of the cutting out of the sutures, since the lead plates com- 
ing in contact with the soft palate exert pressure thereon, and the ten- 
sion, therefore, is not made by the suture alone, which exerts pressure 
on so limited a space, but it is upon the entire length of the palate 
covered by the lead plates. 2. The lead plates serve as a splint, ren- 
dering the palate inflexible to a very great extent. The movements, 
which are almost constant, are suspended; the active muscles are put 
out of use until union of the cleft may take place. 
In conclusion, after using this method of closing the soft palate I feel 
confident that better results in a certain number of cases can be secured 
than by the employment of sutures alone. This is not to take the 
place of the operation of dividing the bones at the malar process and 
carrying the greater portion of the maxillary bones together, but it is 
adapted to the treatment of patients whose bones are well ossified and 
whose deciduous teeth are well erupted. It is in such cases that I 
recommend this operation. CHAPTER VIII. 
SURGERY OF THE ABDOMEN. 
By Maurice H. Richardson, M. D., 
ASSISTED BY FARRAR COBB, M. D. 
Injuries and Wounds of the Abdomen. 
Contusions of the abdominal wall may cause hernia, hemorrhage, 
lacerations, and ruptures of muscles and aponeuroses. Ventral hernia 
from this cause is unusual. The inguinal, the femoral, or the umbilical 
rings may give way as the result of direct blows, though powerful reflex 
contractions of the abdominal wall are a more common cause of hernia. 
(See Hernia.) 
Circumscribed hcematomata and extravasations of blood between the 
layers of the abdominal muscles occur most frequently in the flanks, 
where they may attain great size. Extensive hemorrhage results in 
circumscribed or diffused hsematomata which present characteristic 
signs. 
Unaccompanied by sepsis, even the largest hsematomata are rapidly absorbed, 
and require no treatment beyond rest and cooling applications. Increasing in size 
from persistent bleeding, they may require incision, ligation of vessels, or gauze- 
packing. When sepsis supervenes thorough drainage is demanded. If the serum 
of a hsematoma is withdrawn by aspiration, excessive care is necessary to prevent 
infection. 
Slight and incomplete ruptures of the muscular wall cause transitory pain and 
tenderness without physical signs; complete rupture will cause pain, tenderness, 
muscular weakness, and eventually hernia. 
In extensive ruptures the diagnosis is sooner or later apparent from the 
depression which exists between the separated muscular structures. 
The treatment requires rest, with such external applications as will make 
the patient comfortable. The divided structures may be exposed and sutured 
immediately or after the subsidence of acute symptoms. 
From blows without penetration the abdominal viscera are fre- 
quently the seat of more or less serious lesions. The hollow viscera are 
liable to rupture with extravasation; the solid, to fracture with hemor- 
rhage. Lacerations of the omentum or of the mesentery cause, if 
anything, hemorrhage. After abdominal contusions the earliest pos- 
sible recognition of extravasation or of hemorrhage is demanded. The 
exact seat, nature, and extent of the lesion can be determined only by 
surgical exploration. 
Rupture of the hollow viscera, with extravasation, is marked, as a rule, 
by the symptoms of localized or of general peritonitis; rupture of other 
viscera, by the signs of hemorrhage. Intestinal extravasation after a 
blow is attended by pain, tenderness, vomiting, and distention; the 
abdominal muscles are rigid, the resonance tympanitic. When gas has 
339 340 
SURGERY OF THE ABDOMEN. 
escaped freely into the peritoneal cavity, its presence between the upper 
surface of the liver and the diaphragm usually masks by tympanites the 
liver dulness. The signs of extensive abdominal hemorrhage are faint- 
ness, pallor, rapid and feeble pulse, restlessness, sweating, shallow respi- 
ration, thirst, and cold extremities. Large amounts of blood in the 
abdominal cavity will cause dulness in the flanks. In slight hemorrhages 
pain and faintness are transitory, though the shock is generally out of 
proportion to the amount of blood lost. A local tumor may exist, though 
it may not always be detected. Retroperitoneal hemorrhages may cause 
a prominence, with ill-defined resistance deep in the abdominal cavity. 
Rupture of the Stomach.—Ruptures of the stomach, owing to the 
thickness of its walls and the tendency of the mucous membrane to 
evert, are not ordinarily followed by so rapid or so extensive a perito- 
nitis as rupture of the intestine. In perforations of the posterior wall 
the infection, usually confined to the lesser omental cavity, results in 
subphrenie abscess. Perforations in the anterior wall, especially when 
the stomach is full, are more liable to be attended by extensive extrav- 
asation and general peritonitis. After a blow upon the epigastrium 
pain in that region, with vomiting, tenderness, and muscular rigidity, 
indicates rupture of the stomach. Hsematemesis shows that the stomach 
is at least lacerated. The symptoms of subphrenie abscess following 
such a history are dependent upon rupture of the posterior wall. 
The edges of the wound in rupture of the stomach should be carefully inverted 
and sutured. If the lesion is in the anterior wall, this is comparatively easy; if in 
the posterior, difficult, sometimes even impossible. Extensive lacerations may 
require the infolding of large areas. In case satisfactory closure of wounds in 
either surface is impossible, gauze should be packed about the gastric opening and 
brought out of the abdominal incision. This method ensures rapid adhesion- 
formation and efficient drainage. Hemorrhage should be controlled by means of 
ligatures or of gauze tamponage. 
Rupture of the Intestine.—When the intestinal wall is torn, the 
extravasation is usually so rapid as to produce immediately a general and 
fatal peritonitis, especially if the intestine is tilled with gas and liquid 
faeces. When the intestinal contents are solid, as is generally the case 
below the ileo-csecal valve, the extravasation may be slight and limited, 
and the patient often recovers spontaneously. When the perforation 
is small, eversion of the mucous membrane may limit the extravasation 
to a localized infection or even prevent it entirely. 
Diagnosis.—If the initial pain and tenderness are about or below 
the umbilicus, and the symptoms are rapidly progressive and gas is free 
in the abdominal cavity, it is more likely that the intestine rather than 
the stomach is the seat of rupture; if in the epigastrium, with moderate 
peritonitis and early vomiting, especially if the vomitus contains blood, 
in the stomach rather than in the intestine. Extensive and rapid extrav- 
asations from either stomach or intestines, unaccompanied by haematem- 
esis, can be differentiated only by the seat of the initial pain. At times 
a clear discrimination is impossible. 
Treatment.—When intestinal rupture is suspected the incision 
should be made in the median line, either above or below the umbilicus 
according to the preponderance of symptoms. A region of extreme ten- 
derness, an area of dulness, or a tumor may at times indicate the precise 341 
INJURIES AND WOUNDS OF THE ABDOMEN. 
line of incision. The escape of turbid serum, of gas, or of fecal matter 
the moment the peritoneum is opened proves the existence of some 
serious complication. The seat of the lesion can be found at times only 
by examining the whole intestinal tract. It is important, therefore, to 
have an incision sufficiently long to permit efficient examination. The 
distention usually present in these cases makes thorough inspection with- 
out complete evisceration at times impossible. Extensive exposure of 
the intestines, however, adds gravely to the shock. Exploration should 
therefore be made with as little exposure as possible, and as rapidly as is 
consistent with thoroughness. The intestinal wounds should be closed 
by inverting the peritoneal surfaces and guturing. Coils so extensively 
lacerated that suture is impossible must be resected, and either sutured 
or fastened into the abdominal wound for temporary relief. The peri- 
toneal cavity must be carefully cleansed by irrigation and by drying with 
gauze after repair of the bowel. This step must be preliminary to the 
formation of an artificial anus. 
Rupture of the healthy gall-bladder in some instances causes no 
symptoms beyond those of transitory pain and shock ; in others the con- 
tents of the inflamed and distended gall-bladder are sufficiently septic 
to cause a rapid general infection. In the former the lesion can be 
only suspected; in the latter it may be evident. Peritonitis from this 
cause is seldom so fulminating as in ruptures of the intestinal canal. 
The pain is situated at first in the region of the gall-bladder; later it 
becomes general. 
When rupture of the gall-bladder is suspected, surgical exploration is demanded. 
The rent in the gall-bladder should if possible be sutured ; if this be impracticable, 
temporary drainage by means of a tube or of gauze may be used as in cholecystot- 
omy. The extravasated bile should be removed as thoroughly as possible. 
Rupture of the spleen, the pancreas, or the liver is usually attended 
by signs of hemorrhage, with pain referred to the seat of lesion. Gen- 
eral peritonitis rarely complicates this accident: septic processes in these 
viscera are, as a rule, limited to abscess. For serious hemorrhage inter- 
ference is demanded ; for slight, rest and palliative measures. In many 
cases in which the lesion is obscure and the symptoms trivial, treatment 
must be expectant. In ruptures of the spleen and of the liver the fri- 
ability of these organs makes control of the hemorrhage by ligature or 
by suture difficult, if not impracticable. In hemorrhage from slight 
rents sutures of thread or of catgut may be passed under the lesion by 
means of a round curved needle. They should be tied tight enough to 
control the bleeding, but not tight enough to cut the tissues. In most 
cases, however, the hemorrhage can be successfully controlled only by 
closely packing the wound with gauze. Rupture of the spleen may 
require splenectomy. Hemorrhage from the pancreas may be arrested 
by ligature if the bleeding point can be found; if not, by tamponage. 
In ruptures of the omentum and of the mesentery the chief symptom, 
hemorrhage, can be controlled by ligation. If a considerable portion 
of the mesentery is detached from the bowel, necrosis of the latter may 
follow and require resection. 
The prognosis in ruptures of abdominal viscera is usually serious. 
Intestinal extravasations are generally rapidly fatal. Rupture of the 342 
SURGERY OF THE ABDOMEN. 
stomach results more favorably after interference than rupture of the 
intestines. Simple hemorrhages, extensive enough to produce serious 
exsanguination, are in themselves grave accidents. Hemorrhages of even 
moderate extent, complicated by septic extravasations, usually result in 
a fatal infection. 
In retroperitoneal hemorrhage the source of the blood is obscured by 
the infiltration of the connective tissue. It is best not to make pro- 
longed attempts to find the bleeding point, but to control by means of 
gauze tamponage. The loss of blood may be so moderate as to cause 
few if any symptoms, or it may be so extensive as threaten life. 
In penetrating- wounds of the abdomen, usually caused by gun- 
shots or by stabs and cuts, the abdominal wall may be the seat of extensive 
hemorrhagic infiltration or the source of rapid external bleeding. The 
tendency of a completely divided artery is to contract and to curl up; 
when this occurs deep in the abdominal wall the arterial stream may be 
directed backward into the abdominal cavity, and the latter filled with 
blood before the truth is even suspected. Such an accident has hap- 
pened after cutting the deep epigastric artery in the course of operations 
near the inguinal ring. The epigastric artery may be injured also by the 
use of cutting needles in sewing up abdominal wounds. 
Prolapse, more or less complete, of the omentum, the intestines, the stomach, the 
spleen, the pancreas, the liver, or even the kidney, may take place through incised 
wounds of the abdominal wall. At times evisceration may be extensive. The omen- 
tum of all the abdominal viscera is most likely to escape. The accident occurs not 
infrequently from separation of an abdominal wound, caused by coughing, straining, 
etc. after or even before the removal of the sutures. 
In the treatment of wounds of the abdominal wall it is important 
first to discover and to check a concealed hemorrhage. The presence of an 
external hemorrhage is always conspicuous ; its treatment obvious. The 
wound itself should be carefully cleansed and sutured if it is evident, 
on careful examination, that no injury has been done the abdominal vis- 
cera. Wounds clearly septic should be drained by means of a strand 
of gauze. Prolapsed viscera should be carefully cleansed, and if unin- 
jured replaced. The wound may be sutured immediately unless sepsis 
is feared. 
When the abdominal cavity has been penetrated the wound should be 
enlarged sufficiently to permit satisfactory demonstration of the condition 
of the intra-abdominal organs. 
Gunshot wounds are more likely than stab wounds to lacerate the abdominal 
viscera, especially the intestine, and to tear arteries and veins. A cutting instru- 
ment in the majority of cases will pass between the intestinal coils and do no 
injury to them. It may even miss the blood-vessels of the omentum, the liver, or 
the spleen. Stabs unaccompanied by the signs of either extravasation or hemor- 
rhage do not, therefore, demand exploration in every case, though it is undoubtedly 
the safest plan to investigate thoroughly all such injuries. On the other hand, a 
bullet passing through the abdomen can hardly fail to do serious injury to some 
viscus. Expectant treatment is therefore unjustifiable in gunshot wounds which 
penetrate the abdominal wall, whether the signs of hemorrhage and extravasation 
are present or not. 
Stabs and incised wounds, homicidal, suicidal, or accidental, are produced by 
knives, swords, daggers, razors, glass, and other cutting substances. The external 
opening and the visceral cut may be small and punctured or large and incised. 
The internal lesion may be harmless, or it may cause hemorrhage or extravasation, INJURIES AND WOUNDS OF THE ABDOMEN. 
343 
or both, manifested by characteristic symptoms already described under Visceral 
Rupture. 
Incised wounds of the abdominal viscera may be associated with hemorrhage; 
those of the stomach and intestines, with septic extravasations; of the kidney, 
ureters, and bladder, with the escape of urine; of the gall-bladder, with that 
of bile. 
The symptoms, if any, are those of hemorrhage, of peritonitis, or of 
both. (See Rupture of Abdominal Viscera.) 
The treatment requires exploration in all cases. Hemorrhage 
must be treated by ligation, tamponage, or, in extreme cases, excision of 
the organ (spleen, pancreas, or kidney) if that is possible. Extrava- 
sations, intestinal, gastric, urinary, biliary, and pancreatic, require 
repair of the rent, or, if that is impossible, drainage, with general peri- 
toneal cleansing. Intestinal coils too extensively cut for repair or 
necrotic from injured blood-supply require excision. 
Gunshot wounds of the abdominal viscera have an importance 
far greater than incised or stab wounds. The lesions are more 
severe, their complications more frequent, their results more disastrous. 
Gunshot wounds of modern civil life are chiefly produced by revolvers of 
moderate dimensions, carrying missiles of .22, .32, .38, rarely .44 calibre. 
Abdominal gunshot wounds are usually homicidal and accidental rather 
than suicidal. For the study of gunshot wounds of battle the reader is 
referred to works on military surgery. 
Gunshot wounds as considered in this article are usually produced at short 
range. The force of the impact is great, the penetration extending often to com- 
plete perforation. The clothing is often burned, the skin contused. 
The direction of flight may vary from a straight line to one of inexplicable 
curves. The point of impaction or of exit indicates, therefore, with reference to 
the point of entrance, a definite anatomical track or one so tortuous that the ob- 
server may be completely deceived. In its course through the abdomen the mis- 
sile may cause irreparable damage or trivial laceration. Shock may be severe or 
mild, and in no way proportionate to the external injury. 
The symptoms of gunshot wounds of the abdomen are those of 
hemorrhage, peritonitis, or both. (Vide Peritonitis and Hemorrhage.) 
Treatment.—In gunshot wounds involving the abdominal cavity 
exploration by laparotomy is always indicated in the first hours; after 
an interval of six hours or more without symptoms of either hemor- 
rhage or peritonitis the treatment may be expectant. In other words, 
all gunshot wounds in which injury to the abdominal viscera may have 
occurred demand exploration if seen immediately. Symptoms appear- 
ing late—localized peritonitis and abscess—should be treated by explo- 
ration, incision, and drainage. (See Peritonitis.) 
A gunshot wound of the abdomen, when seen directly after infliction or 
within an hour or two, demands immediate investigation whatever the 
symptoms. The wound of entrance must be explored under complete 
anaesthesia. If it appear that the missile has been deflected from the 
peritoneum, an antiseptic pad to the wound of entrance will suffice. If 
penetration of the abdominal cavity has taken place, either the wound 
must be enlarged or an incision must be made over the viscus most 
probably involved. In doubtful cases is required a median incision, even 
if the wound of entrance is remote. When the line of flight is toward 
or even across the centre of the abdomen, that incision should be selected 344 
SURGERY OF THE ABDOMEN. 
which permits the most efficient exploration of the whole abdominal 
cavity. 
As soon as the peritoneum is nicked the escape of blood, of serum, or of gas and 
fecal matter will show that further exploration is necessary. When nothing 
abnormal appears at the peritoneal incision, further exploration is wise, to make 
sure that no serious lesion can possibly exist. Doubtless the external wound 
may safely be closed in most cases. 
Serious lesions must be treated according to their situation and 
character—hemorrhage by ligation of vessels or bv gauze tamponage ; 
intestinal, gastric, gall-bladder, and urinary-bladder rents by suture. 
(See Rupture of Stomach and Intestine, and Hemorrhage.) If the 
hemorrhage has ceased, the blood in the abdominal cavity should be 
thoroughly removed. 
Intestinal extravasation requires most thorough investigation and 
repair. Every wound must be sutured with extreme care; coils too 
badly lacerated for suture may require excision with suture, anastomosis, 
or artificial anus. (See Operations on Intestine.) In extreme cases 
the injured bowel may be sutured temporarily into the abdominal wound. 
Inasmuch as the intestinal perforations may be multiple, and some of 
them hard to find, inflation of the gut through the anus with hydro- 
gen (Senn), with air, or with fluid may be employed to demonstrate the 
integrity of the bowel-wall. 
Gunshot wounds of the abdomen of some hours' standing require exploration if 
symptoms of persistent hemorrhage or of peritonitis exist. For hemorrhage the 
usual methods of treatment should be applied; for peritonitis the treatment of 
peritonitis (q. v.). Intestinal perforations must be closed and the peritoneal cavity 
cleansed. 
When seen after the lapse of a few days gunshot wounds of the abdomen are 
likely to present only the symptoms of localized peritonitis and abscess, for cases 
of severe hemorrhage and of penetrating intestinal wounds no longer survive. 
Localized peritonitis and abscess require incision and drainage. 
Gunshot wounds of the liver, spleen, pancreas, kidney, and bladder, ureters, and 
great vessels require the surgical repair practicable—hemorrhage by ligation and 
gauze tamponage; lacerations destroying the utility of the organ, by excision 
when possible; rents with extravasation, by suture. 
In all cases of gunshot wounds examination of the superficial structures of the 
part of the body opposite to the wound of entrance must be made. Emergence of 
a bullet is often prevented by the elasticity of the skin. Not that removal of a 
bullet is important, however, though its extraction is always a matter of satis- 
faction. 
Gunshot wounds unexplored should be disinfected as well as possible, and 
sealed with an antiseptic pad. 
In thin patients the presence of bullets and certain other foreign bodies may 
be detected by the use of the Rontgen rays. 
Surgery of the Stomach. 
Congenital Malformations of the Stomach.—The stomach may be 
transposed; it may be abnormally small. Atresia of the pylorus has 
been observed, usually associated with hypertrophy of the muscular 
walls of the stomach ; also hour-glass constrictions unaccompanied by 
signs of previous disease. Surgical interference is demanded but rarely 
in these conditions. (For acquired malformations see Ulcer and Dila- 
tation of the Stomach. For Rupture, Contusion, and Penetrating 
Wounds of the Stomach see page 340.) SURGERY OF THE STOMACH. 
345 
Ulcer of the stomach has recently acquired surgical importance 
from the encouraging results which have followed prompt interference 
in hemorrhage and in perforation, lesions previously regarded, if not 
necessarily fatal, as beyond relief. 
Ulcer of the stomach occurs usually in young girls, though it may appear in 
both sexes at any age. The direct cause of ulcer is ischaemic necrosis of a circum- 
scribed area of the gastric wall, due to diminished vascular supply, the etiology 
of which is obscure. The ulcers are usually single and small, and are situated 
most frequently near the pylorus, along the lesser curvature. They may be exten- 
sive or multiple, however, and involve other portions of the stomach. The shape 
is usually that of a truncated cone, the base of which is toward the interior of the 
stomach. The local necrosis is followed by digestion of the necrotic tissues. In 
the course of the digestive and gangrenous process an artery of considerable size, 
such as the gastric, may be eroded and cause alarming hemorrhage. From the 
whole ulcerated surface a slow capillary ooze may take place. The process may 
not stop with the digestion and separation of the sphacelus; it may continue 
even till perforation of the stomach wall ensues. The overlying peritoneum may 
become infected and adherent to contiguous structures. By this provision per- 
forations are limited to the gastric wall or the neighboring viscera. Rapid ne- 
croses not shut off by adhesions from the peritoneal cavity permit immediate ex- 
travasation of the gastric contents. The cicatricial tissue resulting from the spon- 
taneous healing of gastric ulcers may cause deformities in the stomach (hour-glass 
stomach) or stricture at or near the pylorus. 
Symptoms and Course.—Gastric tdcer may give rise to no symp- 
toms whatever until sudden perforation or hemorrhage occurs. In 
other cases epigastric pain and discomfort suggest the lesion. The 
usual symptoms are gastric irritation and discomfort, with more or less 
pain. Vomiting after eating sometimes occurs. The pain is boring in 
character, and is often referred to the back : hemorrhage causes either 
vomiting of blood, usually bright in color, or tarry stools. Continual 
persistent hemorrhage produces a characteristic waxy anaemia. The most 
important symptoms surgically are those of hemorrhage and of perfora- 
tion. In perforations guarded by adhesions no symptoms, except those 
of the ideer itself or of local peritonitis, are usually present. 
Perforations into the abdominal cavity cause the symptoms of a general peri- 
toneal infection. (See General Peritonitis.) Occasionally, as the result of perfo- 
ration, abdominal abscess, pyothorax, subphrenic abscess, abscess of the pancreas 
and spleen, with or without perforation of the diaphragm, are observed. (See 
Subphrenic Abscess.) 
The diagnosis of gastric ulcer rests upon the symptoms above given. 
It must be differentiated from cancer of the stomach—a distinction 
usually easy. Simple ulcer of the stomach, occurring at an age when 
cancer is common, can only with difficulty be distinguished from the 
latter. The chief diagnostic points of difference are the duration of 
the symptoms, the age of the patient, the presence of hydrochloric 
acid in excess, and the absence of the characteristic cachexia of cancer. 
A localized movable tumor favors the diagnosis of cancer. (See also 
Cancer of the Stomach.) 
Treatment.—Surgical interference in gastric ulcer is indicated—(1) 
in the symptoms of rapid and dangerous hemorrhage ; (2) in the anaemia 
caused by the persistent, slow loss of blood; (3) in perforations with 
general extravasation; and (4) in localized peritonitis with abscess. 
The exploratory incision made in the median line may be extended 
transversely in case the stomach is contracted or small. The anterior 346 
SURGERY OF THE ABDOMEN. 
surface and the lesser curvature, where the lesion is most apt to occur, 
should be examined first. By separating the layers of the lesser omen- 
tum most of the posterior wall of the stomach can be examined, dig- 
itally or visually. Inflammation of the peritoneum frequently shows 
the seat of the ulcer. In some instances the lesion can be detected by 
the sense of touch. The seat and extent of the ulcer having been de- 
termined, the disease may be treated (1) by infolding the whole ulcer- 
ated area; (2) by excision of the idcer with subsequent suture; (3) by 
uniting the peritoneum around the ulcer to the abdominal wound; (4) 
by walling off the idcer from the general peritoneal cavity with sterile 
gauze. 
The choice of methods depends upon the symptoms which indicate 
interference—whether from hemorrhage or from perforation. For 
perforations, infolding, excision, suture to the wound, or gauze packing 
may be practised, according to the size, shape, and situation of the 
lesion; for hemorrhage, all the methods except infolding. 
(1) Infolding consists in uniting the lax walls of the stomach over the affected 
area, which is deeply depressed for this purpose by the fingers or by an instrument. 
The peritoneum is united by means of continuous or interrupted Lembert sutures. 
(2) Excision and suture are applicable in both hemorrhage and perforation. 
The tissues should be freely excised beyond the limits of the disease, and the 
wound closed by inverting the peritoneum with a continuous or an interrupted 
stitch. The direction of closure must depend upon the size and shape of the 
resulting wound. 
(3) Suture to the abdominal wound is to be resorted to when the gap resulting 
from excision is such that closure of the stomach is impossible or in cases in which 
excision is for some reason impossible. 
(4) Packing with gauze remains as the only resort in case neither suture of the 
stomach nor approximation to the abdominal wound is possible. Ulcers in the 
posterior wall may require this method of treatment. 
If hemorrhage into the stomach is alarming, the stomach should be 
opened so as to give a clear view of the field. The bleeding surface 
may then be ligated or cauterized. If an artery of considerable size 
is bleeding, a thread may be passed under it by means of a curved 
needle and tied. The stomach wound may then be closed or it may be 
united to the ventral cut. Localized peritonitis with abscess should be 
treated by incision and drainage. Perforations guarded by adhesions 
may result in gastric fistulse. (See Gastric Fistulae.) 
Localized peritonitis, when spontaneously healed, may result in painful adhe- 
sions to contiguous viscera, especially the duodenum, gall-bladder, and pancreas. 
Subphrenic abscess may arise from any cause by which the lesser 
cavity of the omentum or the under surface of the diaphragm becomes 
infected. The most common cause is the perforation of a gastric or 
duodenal ulcer; more rarely extension of infective perforations of the 
vermiform appendix or of the gall-bladder. Subphrenic abscess either 
makes its way to the surface by adhesions or it breaks into the peri- 
toneal or into the pleural cavity. Adhesions to the diaphragm, especi- 
ally on the left side, may cause rupture into the pleural cavity or into the 
pericardium. A pyo-pneumothorax without other cause should suggest 
the possibility of direct infection through the perforation of gastric 
ulcer or indirect through the rupture of a subphrenic abscess. 
The symptoms of subphrenic abscess are those of a deep epigastric SURGERY OF THE STOMACH. 
347 
inflammation—pain, fever, with constitutional infection. A tumor may 
be felt in the epigastrium, or even in the region of the liver or of the 
spleen. 
The diagnosis is often difficult on account of the deep situation of 
the affection. It depends (1) upon a history of gastric ulcer; (2) upon 
the local signs of an epigastric tumor, with local pain and tenderness 
and general systemic disturbances; and (3) upon aspiration. Unless 
the swelling is at the surface, aspiration is too dangerous to be employed 
for diagnostic purposes. 
The treatment of subphrenic abscess is drainage. This should 
be accomplished, if possible, without breaking down adhesive barriers. 
The incision should therefore be made over the most prominent portion 
of the tumor. In case the anterior abdominal wall is not adherent, 
and in case the abscess does not point externally elsewhere, incision and 
drainage must be made through the median line above or below the 
stomach, according to the situation of the tumor. Subsequent treatment 
should be like that of other abdominal abscesses. 
Abdominal abscesses resulting from the perforation of gastric 
ulcers or from other causes in the immediate vicinity of the stomach 
give rise to localized, tender, and painful tumors with characteristic 
physical signs. They should be treated like abscesses elsewhere. 
Gastric fistulae result usually from the perforation of gastric ulcers 
through the anterior wall of the stomach and of the abdomen. They 
may be caused, however, by direct injuries to the stomach or by the 
presence of foreign bodies. Internal fistula; result from perforations 
into contiguous portions of the alimentary tract. The latter rarely give 
rise to symptoms. 
Gastric fistulse, like intestinal, usually heal spontaneously. Such as 
do not by themselves close under cleanliness and stimulation may be 
treated by nitrate of silver, the actual cautery, mechanical approxima- 
tion by means of straps or cr6pe lisse, or by resection of the sinus, with 
suture. 
After the failure of persistent efforts in this direction closure may be ensured 
by separating the stomach from the abdominal wall, so that the freed and lax 
edges of the gastric opening may be resected, inverted, and sutured. The com- 
plete separation of the stomach usually necessary in this procedure causes some 
danger of general peritoneal infection. Care must be taken, therefore, to prevent 
the escape of gastric contents. Preliminary lavage is essential. The whole stom- 
ach being freed from its attachment, inversion and suture are easy. A strand of 
gauze should be left in the abdominal wound in contact with the line of suture 
to provide against extravasation. 
New Growths of the Stomach.—Though carcinoma is by far the 
most important neoplasm of the stomach, sarcomata, adenomata, and 
myo-fibromata have been observed. The last three, from their rarity, 
have little surgical importance, though one or two large sarcomata and 
one adenoma have been removed from the stomach-wall. 
Cancer of the Stomach.—Cancer is more frequently seen in the 
stomach than in almost any other part of the body. It is usually of 
the scirrhous variety, and is a disease of adult or advanced years. 
Cancer is situated usually at the pylorus, less frequently at the cardia, 
and least frequently in the main body of the stomach. 348 
SURGERY OF THE ABDOMEN. 
The CAUSE of cancer of the stomach is uncertain. The growth may involve 
the inner layers of the stomach as a flat, eroded surface unaccompanied by tumor. 
The affected walls, on the other hand, may be thickened, sometimes to an extreme 
degree, so that the tumor may be felt through the epigastrium. In other cases no 
tumor will be perceptible. At times the whole anterior wall of the stomach is 
infiltrated with an enormous mass of new growth. The internal surface of the 
cancer may become necrosed and eroded; digestion of the necrotic area may result 
in hemorrhage or in perforation. The edges of the ulcer are irregular, the base 
uneven and necrotic; the gastric wall may be excessively thickened or by ulcera- 
tion thinned and friable. The peritoneum over the affected surface may become 
adherent to surrounding organs. Perforations may take place and cause fatal 
peritonitis, or limiting peritoneal barriers may guide the extravasation into other 
viscera. Infection of the lesser omental cavity may result in subphrenic abscess; 
of contiguous viscera, in localized abscesses; of the abdominal cavity, in peritonitis. 
The hemorrhage in cancer is usually slight. Digestion gives the blood the 
familiar coffee-grounds color. 
Cancer situated at the pylorus often causes stricture with dilatation 
of the stomach. The infection of lymph-nodes appears late, if at all. 
Symptoms.—The first symptoms of cancer of the stomach are dis- 
turbances of digestion, generally associated with constipation. Pain is 
next observed, sharp in character and aggravated by food, with vomit- 
ing after eating, gradual loss of weight, and cachexia. The vomitus 
often contains digested blood resembling coffee-grounds. Free hydro- 
chloric acid in the gastric juice may be diminished or wanting in exten- 
sive gastric cancer. Too much reliance must not be placed upon this 
symptom, because hydrochloric acid may be diminished or absent in 
certain other diseases, and because, even if present in normal amounts, 
gastric cancer may nevertheless exist. 
The tumor of gastric cancer is often imperceptible, especially in the 
early stages, when radical operative extirpation is possible. When con- 
spicuous, the tumor is usually situated at the pylorus or in the anterior 
wall. Situated in the posterior wall or near the cardia, it cannot, unless 
very large, be detected by palpation. 
The tumor of gastric cancer is usually hard and tender; it may be smooth or 
nodulated, globular and sharply defined, or a flattened oval and gradually merging 
into the surrounding structures. It may be superficial and extensively mobile or 
firmly and deeply fixed. At times the tumor will be found with extensive contig- 
uous metastases. The relation of the tumor to the stomach can usually be deter- 
mined by the aid of lavage, inflation, or by the use of the gastro-diapha'noscope. 
Cancer-cells can sometimes be detected in the vomitus or in the washings. Dila- 
tation of the stomach, often to an extensive degree, due to pyloric obstruction, is 
usually present. 
The chief points of difference between ulcer and cancer of the stomach are as fol- 
lows: Cancer occurs usually at or after adult life, ulcer in late youth. Pain, 
usually present in cancer, is sharp, referred to the shoulder, and increased by 
food ; that of ulcer, boring through the back, relieved by food. Blood vomited in 
ulcer is usually fresh and bright; in cancer it resembles coffee-grounds. In cancer 
there usually is a tumor; in ulcer, none. The symptoms of ulcer often extend 
over a long period of time without affecting markedly the weight, general 
appearance, or strength; cancer, a progressive disease of comparatively short 
duration, affects early and profoundly the constitution. In ulcer the cachexia is 
usually that of loss of blood—a distinct ana?mia; in cancer, even with the loss of 
blood, it is conspicuously the cachexia of malignancy. Free hydrochloric acid is 
diminished or absent in cancer; it is increased in ulcer. 
The surgical treatment of cancer of the pylorus is either radical 
or palliative. Pyloric stenosis requires either radical excision of the 
disease with suture, or anastomosis between the stomach and the jeju- FOREIGN BODIES IN THE STOMACH. 
349 
num. Perforations with extravasation may require immediate inter- 
ference and repair unless the patient’s chances of life are, from the 
advanced condition of the disease, necessarily too small to make sur- 
gical intervention worth while. Hemorrhage is rarely severe enough 
to demand operation. Even if extensive, the wisdom of surgical inter- 
vention may well be questioned. When palliation and medical treat- 
ment are unsuccessful, the shock of operative measures is not likely to 
be safely borne by an exsanguinated patient. 
Stricture of the Pylorus.—The causes of pyloric stricture are— 
(1) Congenital malformations; 
(2) Cicatricial contraction of ulcers; 
(3) Malignant and benign tumors ; 
(4) Twists at or near the pylorus; 
(5) External pressure from growths; 
(6) Spastic contractions. 
Congenital atresia, though very rare, has been observed. Cicatrized 
ulcers situated near the pylorus frequently result in permanent stenosis. 
The lumen may be considerably diminished without causing symptoms; 
it may be more or less restored by ulceration after a temporary nar- 
rowing. Complete atresia is rarely, if ever, seen. Malignant disease 
involving the pylorus obliterates it more or less completely. Twists 
may take place in the pylorus of a dilated stomach, especially when the 
abdominal walls are extremely relaxed. Tumors of the liver, the gall- 
bladder, the pancreas, the omentum, or the retroperitoneal space by 
pressing upon the pylorus may diminish its lumen. Movable kidney 
and spleen have been said to cause obstruction by dragging on the 
stomach. The existence of spastic stricture of the pylorus is doubtful. 
The symptoms of pyloric stenosis are those of dilatation of the 
stomach—malnutrition and impaired digestion, with decomposition of 
food. The dilatation may be extreme; the stomach may extend into 
the left flank, into the pelvis, or even into the right flank. Sagging with 
fluid and distended with gas, it gives rise to marked succussion. 
The palliative treatment of dilated stomach is systematic lavage, 
massage, and electricity. Dilatations which result from atony may be 
so much improved by this treatment that operative measures are unne- 
cessary. The radical treatment of pyloric stenosis consists in mechanical 
dilatation (Loreta’s operation), pylorectomy, pyloroplasty, gastro-enteros- 
tomy, or pylorectomy combined with g astro-enter ostomy. (See Operations 
on the Stomach.) 
Foreign Bodies in the Stomach 
Foreign bodies in the stomach may have been swallowed as a 
single object or they may have been gradually formed of small, indigest- 
ible substances agglutinated. The commonest foreign body is a plate of 
teeth. Almost every conceivable thing that can be held in the mouth 
has been swallowed. Large balls of hair and straw have been found in 
the stomachs of the insane. Asa rule, a rounded body that can pass 
the oesophagus will also pass the pylorus. Sharp or angular objects 
frequently fail, however, to pass this orifice. 350 
SURGERY OF THE ABDOMEN. 
Foreign bodies in the stomach may give rise to no symptoms what- 
ever. If very large, they may cause obscure digestive disturbances. If 
small enough to become impacted, but too large to pass the pylorus, 
symptoms of obstruction ensue. Sharp objects penetrating the stomach- 
wall may give rise to localized or to general peritonitis. 
The indications for operation upon the stomach in cases of suspected 
foreign bodies are pain, localized tenderness, fever, and the physical 
signs of pyloric obstruction or extravasation. Gastrotomy is the ope- 
ration indicated for removal. (See Gastrotomy.) 
Operations upon the Stomach. 
Preliminary Treatment.—Whenever it is proposed to open the 
stomach, preliminary lavage and rectal feeding should be employed, for 
it is essential that the stomach be both empty and clean. It may be 
washed out with warm water or with a solution of boric acid. 
Gastrotomy—i. e. making a temporary opening into the stomach—is 
resorted to in the extraction of foreign bodies and as a preliminary step 
to certain operations upon the oesophagus and upon the pylorus. The 
incision through the abdominal wall, two or three inches in length, 
should be made in the median line above the umbilicus. When the 
stomach is small and contracted the cut must be enlarged longitudinally 
and sometimes transversely. 
The principal care in opening the stomach should be to prevent 
extravasation of its contents; hence the importance of preliminary 
lavage and of gauze placed about the line of the proposed gastric incis- 
ion. The stomach should be incised in the longitudinal axis, halfway 
between the greater and the lesser curvatures. If but a small opening 
is necessary, it may be made transversely. Operations upon the oesoph- 
agus can best be accomplished by an incision not far from the pylorus. 
By putting the lesser curvature on the stretch a sulcus is made through 
which the instrument glides into the oesophagus. For operations upon 
the pylorus the cut must be made near enough to permit easy reach of 
the pyloric orifice by the finger. In extracting foreign bodies care must 
be taken not to lacerate the edges of the gastric incision. In closing 
the wound of the stomach the mucous membrane should first be united 
by a continuous suture. After this the serous edges should be inverted 
and fastened by the interrupted Lembert, by the Halsted quilted suture, 
or by the continuous Lembert. As a rule, the joint will be so satisfac- 
tory that the external wound may be closed immediately. In cutting 
through the stomach-wall the hemorrhage is chiefly from the mucous 
membrane. This can be controlled by the continuous suture. 
Gastrostomy consists in making a permanent opening into the 
stomach. It is indicated in inoperable strictures of the oesophagus, 
malignant or benign. The operation was first performed successfully 
in 1874. 
By the early methods the stomach was first stitched to the abdominal wound; 
some days later, after it had become firmly adherent, a permanent opening was 
made. 
Fenger exposed the organ by an incision along the left costal border; Yon 
Hacker, by a cut through the left rectus muscle. OPERATIONS UPON THE STOMACH. 
351 
Fig. 153. 
Gastrostomy: Witzel’s method. Tube in position; sutures ready to tie. 
The disadvantage of the earlv operations was leakage. Of the recent 
methods, devised to obviate this difficulty by making an oblique fistulous 
tract in the stomach-wall, that of Witzel is the most efficient. By this 
Fig. 154. 
Gastrostomy: Witzel’s method. Tube in position; sutures ready to close abdominal wall. 
method a tube is infolded in the stomaeh-wall by peritoneal approxima- 
tion, as shown in Fig. 153. The stomach is stitched to the abdominal 
wall (Fig. 154), and the external wound is closed. 352 
SURGERY OF THE ABDOMEN. 
The manipulations can usually be made outside the peritoneal cavity. 
No secondary operation to open the stomach is needed. Feeding through 
the tube may begin immediately after the operation. The tube should 
not be removed for the first time until the expiration of a week. Con- 
traction of the fistula may be prevented by removal and reintroduction 
of the tube at frequent intervals. 
Loreta’s operation consists in preliminary gastrotomy and digital 
or instrumental dilatation of either the cardiac or the pyloric orifice of the 
stomach in cases of non-malignant stricture. This operation was first 
performed in 1882. The majority of the cases have been stricture of 
the pylorus. In the preparation of the patient and the opening of the 
stomach the technique does not differ in any way from that of gastrot- 
omy. The gastric incision should be within easy digital reach of the 
Fig. 155. 
pyloric opening, and should be in the longitudinal axis. Dilatation of 
the stricture should be carefully effected by means of one or more fingers 
Pyloroplasty: incision. 
Fig. 156. 
Pyloroplasty, showing gain in calibre by method of suturing. 
or by bougies. Hemorrhage and rupture of the stomach may complicate 
this operation ; the stricture may recur. 
Pyloroplasty rather than digital divulsion should be the operation 
of choice for benign strictures of the pylorus. It consists in taking out OPERATIONS UPON THE STOMACH. 
353 
a double V- or diamond-shaped piece in the longitudinal axis of the 
pylorus, on the anterior surface, as in Fig. 155. This incision is sutured 
transversely, as shown in Fig. 156. 
Pylorectomy.—Pylorectomy, or resection of the pylorus, was first 
successfully performed by Billroth in 1881. The operation is indicated 
in malignant strictures of the pylorus in which the disease is limited to 
the stomach, and in benign strictures in which a pyloroplasty will not 
Fig. 157. 
Incision for pylorectomy. 
afford relief. Preparation for the operation consists in rectal feeding 
and gastric lavage. 
The stomach should be exposed by a median abdominal incision 
Fig. 158. 
Pylorectomy: pylorus excised; stomach-opening partially closed, ready for suturing to the 
duodenum. 
above the umbilicus, long enough to permit free inspection and manipu- 
lation. The stomach and upper part of the duodenum should be pulled 354 
SURGERY OF THE ABDOMEN. 
out of the wound, and the abdominal cavity walled off with gauze, 
llesection of the diseased portion should be thoroughly effected by cut- 
ting well above and below the lesion through sound tissues. The result- 
ing openings in the stomach and duodenum must next be fitted together 
according to their size and shape, as suggested in Figs. 158, 159. If 
they cannot be satisfactorily united, these openings must be closed and 
a gastro-enterostomy performed (q. v.). (See Figs. 158, 159.) 
Coaptation of the divided structures should be made by the Lembert 
stitch. (See Figs. 158, 159.) To prevent extravasation, strands of 
Fig. 159. 
Pylorus resected: gastro-enterostomy completed. 
sterile gauze may be placed against the line of suture and led out of 
the abdominal wound; these may be removed on the third day. 
The mortality of pylorectomy has been very high (over 70 per 
cent.); this is due mainly to the unfavorable nature of many of the 
cases. 
Combined pylorectomy and gastro-enterostomy consists in ex- 
cision of the pylorus, closure of the divided stomach and duodenum, 
and the formation of a lateral anastomosis between the stomach and 
the jejunum. 
This procedure has had a mortality slightly less than pylorec- 
tomy, probably due to the greater rapidity with which it may be accom- 
plished. 
Gastro-enterostomy is an anastomosis between the stomach and 
some portion of the intestine, preferably the jejunum. It is indicated 
in cases of malignant disease of the pylorus in which the process has 
extended to the walls of the stomach, or in which neighboring structures 
are involved, or when there is extensive metastasis. It is sometimes 
indicated in benign stenosis with extensive adhesions, in which pylorec- 
tomy, pyloroplasty, or dilatation is impossible. 
Gastro-enterostomy should be performed by joining a loop of intes- OPERATIONS UPON THE STOMACH. 
355 
tine to the posterior wall of the stomach by sutures or by some mechan- 
ical aid (Fig. 160). Von Hacker in 1883 showed that anastomosis on 
Fig. 160. 
Pylorectomy: gastroenterostomy. 
the posterior stomach-wall was essential, but this cannot be accomplished 
when the stomach is bound down by adhesions. 
To prevent stagnation of food and bile in the unused portion of the 
duodenum several additional anastomoses between intestinal coils have 
been suggested by Braun. 
Gastrorrhaphy is an operation devised to reduce the size of a dilated 
stomach. It has been performed but rarely, and consists in making a 
single or double plait in the anterior wall of the stomach, the peritoneal 
surfaces being sutured together to hold the folds in place. Theoretically 
it may be successfully applied in cases of simple chronic dilatation which 
are not relieved by lavage. 
Operations for Painful Gastric Adhesions.—Adhesions of the 
stomach to the abdominal wall or to the neighboring viscera, occurring 
as a remote result of gastric ulcer, may cause severe gastralgia. In 
numerous cases, after failure of palliative treatment, exploratory lapa- 
rotomy with free division of the adhesions has effected a complete cure. 
Gastro-anastomosis consists in making an anastomotic communica- 
tion between the cardiac and the pyloric ends of the stomach in cases of 
extreme hour-glass contraction of that organ. The operation has been 
performed but three times up to the present year (1896). 356 
SURGERY OF THE ABDOMEN. 
SURGERY OF THE INTESTINES. 
(For wounds and ruptures, see page 340; for non-traumatic perforations, see 
Typhoid Ulcers, Tuberculosis, Cancer, Appendicitis, and Fecal Fistulae.) 
The most important anomaly of the intestine is Meckel’s diverticulum, 
which from its possible situation, size, and relations may cause acute 
obstruction or bowel-necrosis, or both. 
Congenital atresice may occur at the ileo-csecal valve and in the ileum 
and the jejunum. Doubling of the small intestine, a rare and unim- 
portant anomaly, has been observed. 
Intestinal Obstruction. 
Intestinal obstruction may result from lesions which contract or 
obliterate the intestinal lumen, or it may be dependent upon a paresis of 
the muscular wall of the bowel, of septic or of inflammatory origin. The 
former only are considered as true obstructions. 
Acute obstructions are caused, as a rule, by mechanical lesions not 
associated with disease. Simple mechanical closure of the intestinal 
canal may be congenital; it may be caused by intussusception, volvulus, 
internal and external strangulation, kinks and flexures, and the impac- 
tion of foreign bodies. The passive obstruction dependent upon intes- 
tinal paresis is seen in general peritonitis, in mesenteric embolism, and 
thrombosis. 
Chronic obstructions are caused by disease—by new growths, benign 
and malignant, involving the intestinal wall, by the pressure of external 
growths and inflammatory masses by cicatricial strictures after intes- 
tinal ulceration. Chronic and intermittent obstructions sometimes occur 
as the result of faulty adhesions and internal incarcerations. 
Acute Intestinal Obstruction.—Bands, Kinks, and Flexures ; Inter- 
nal Strangulation.—The commonest form of mechanical obstruction is 
that due to the various forms of external hernia. (See chapter on Her- 
nia.) A Meckels diverticulum may cause acute obstruction with strangu- 
lation either of itself or of an intestinal coil. Bands occasionally exist 
without antecedent inflammation and without interfering with the intes- 
tinal stream ; they may suddenly, however, without apparent cause, pro- 
duce complete or partial obstruction. A protrusion of the intestine 
through an opening in the mesentery or in the omentum or under a band 
resembles greatly the lesion of an ordinary hernia, and has been called 
internal strangulated hernia. Retroperitoneal hernia—i. e. prolapse of 
the intestine into an abnormal peritoneal pouch, either at the fossa 
duodeno-jejunalis or in the region of the caecum or the sigmoid flexure 
—is a form of internal hernia that may cause acute obstruction. 
Strangulation of an intestinal coil through the foramen of Winslow is 
a very rare accident. Foramina in the mesentery or in the omentum 
cannot be explained except as the result of trauma, of operation, or of 
congenital influences. Kinks and flexures result from faulty adhesions. 
Bands dependent upon such adhesions may occur after any form of 
general or of partial peritonitis, after operations, in the course of ectopic 
gestations, and without known cause. Adhesions in their effects may 
vary between extreme limits. A single point of faulty attachment may INTESTINAL OBSTRUCTION. 
357 
produce a constricting loop; on the other hand, a total matting together 
of intestines, uterus, tubes, and ovaries, no mechanical obstruction 
whatever. 
As a rule, the former is more productive of obstruction than the latter. A 
single band may compress the intestine transversely or it may strangle a whole 
coil. Kinks and flexures are produced by the adherence between a coil and a 
contiguous viscus—between the small intestine and a uterine horn, or between the 
intestine and the scar of a vaginal hysterectomy. Changes in the size of the uterus 
or in the depth of the contracting vaginal cicatrix may drag the adherent coil into 
a sharp angle, by which, under ordinary conditions, no obstruction is produced. 
Distention of the proximal coil by pressure against a solid viscus or against the 
Fig. 161. 
Meckel’s diverticulum causing fatal obstruction (Dr. H. W. Cushing, Warren Museum). 
pelvic brim may suddenly occlude the outlet into the distal lumen, producing a 
valve which is tightened more and more by the increasing distention. Separation 
of the adhesion at once relieves the tension, opens the valve, and restores the lumen. 
The intestinal coils are frequently extensively matted together, at times with 
more or less obstruction. Single or multiple fistulae occasionally exist between the 
coils. 358 
SURGERY OF THE ABDOMEN. 
Congenital obstructions, though rarely found except in the rectum and 
the anus, have been observed in the duodenum, the jejunum, the ileum, and 
at the ileo-csecal valve. Congenital defects due to Meckel’s diverticulum 
are much more important. In this malformation, the ileum either com- 
municates directly with the umbilicus or is attached to it by means of a 
fibrous cord or band. Pressure from this prolongation not infrequently 
results in strangulation of an intestinal coil or of the diverticulum itself. 
(See Fig. 161.) 
Acute obstructions result occasionally from the impactions of foreign 
bodies, gall-stones, enteroliths, and intestinal worms. Foreign bodies 
seldom become impacted in the intestine after leaving the pylorus 
unless they have sharp edges or angles. Objects small enough to pass 
the normal intestine may cause pathological changes by which they 
become permanently arrested; ulceration and even perforation may 
result, with cicatricial stricture as a remote possibility. When stricture 
is present a body no larger than an orange- or apple-seed may produce 
the first symptoms of obstruction. Enteroliths are usually formed upon 
gall-stones, though they may be composed entirely of fecal substances or of 
phosphates combined with animal matter. Obstructions from gall-stones 
usually occur in women of advanced age. The calculi make their wray by 
slow ulceration from the gall-bladder into the duodenum. The seat of 
the impaction is usually in the small intestine. (See Plate VIII.) 
Intestinal obstruction by masses of round-worms has occasionally 
been observed in children. 
Intussusception.—Of all the cases of acute intestinal obstruction, 
30 per cent, are due to intussusception. The majority of cases occur in 
children. Among adults it is more common in women than in men. 
The situation of an intussusception is usually at the ileo-csecal valve, the 
small intestine being invaginated into the large. The process may be 
confined, however, to the small intestine. In rare instances a double 
invagination may occur, or even a retrograde telescoping. 
Pathology.—An intussusception consists of three layers of bowrel, 
that which is received being called the intussusceptum, and that which 
receives, the intussuscipiens (Figs. 162, 163). 
Most of the cases are at the ileo-caecal valve. Spontaneous recovery by slough- 
ing and elimination of the intussusceptum occurs in about 40 per cent, of the cases, 
but spontaneous recovery is not always permanent, for death may take place sub- 
sequently from perforation of the intestine; moreover, stricture of the gut is very 
likely to occur. Recovery after intestinal resection in children with this form of 
obstruction is almost unknown. The longer operating is delayed the greater the 
mortality. Operations performed on the first or second day are by far the most 
successful. 
The causes of intussusception are generally obscure; occasionally, however, 
they are obvious, as when an intestinal polyp is found. Predisposing causes are 
irregular peristalsis, feeble health, diarrhoea, adhesions of the bowel. 
The symptoms of intussusception are chiefly those of acute intestinal 
obstruction, and are usually without premonition, though some predis- 
posing causes may have been observed. The pain, rapidly increasing 
in severity, is due partly to violent intestinal contractions, and partly to 
dragging and pressure upon the mesentery, with distention of the intus- 
suscipiens and beginning necrosis of the intussusception. Vomiting, dis- 
tention, and collapse appear early. The characteristic symptom is the PLATE VIII. 
Enterolith with Gallstone for a Nucleus ; Removed by Enterotomy. (Richardson.) INTESTINAL OBSTRUCTIONS. 
359 
passage of blood and mucus from the rectum. This form of acute 
obstruction unites with the symptoms of stenosis those of acute gan- 
grene ; hence the fulminating nature of the disease. 
In rare instances, however, invagination may be slow, and the intussusceptum 
may accommodate itself to the altered conditions without necrosis and without 
violent symptoms. If the abdominal walls are thin and if distention is slight or 
absent, an ill-defined sausage-shaped tumor can generally be detected; if the 
abdominal walls are thick and if distention is excessive, the tumor, unless very 
large, cannot be felt. If the intussusception is low down, the invaginated bowel 
may be felt through the rectum. 
Treatment.—The treatment of intussusception may be palliative 
or operative. Palliative measures include massage, rectal injections with 
Fig. 162. 
Fig. 163. 
Intussusception (Warren Museum). 
Intussusception at the junction of the small and large 
intestine. The former has passed outward and the 
caecum retains its place, the appendix projecting from 
the neck of the invagination (Warren Museum). 
the patient inverted, and inflations of the colon with air or gas. It is 
doubtful, however, in a clear case of intussusception whether time ought 
to be taken for palliation. The excessive mortality in this disease is 
largely due to delay in applying radical surgical treatment; it is best, 
therefore, if attempts at reduction by non-operative measures be used, 
that they be as brief as possible if not immediately successful. 
Reduction of the invagination hv inflation and enemata is not possible after 
the invaginated portion has become swollen from the constriction of its efferent 360 
SURGERY OF THE ABDOMEN. 
vessels and fixed by adhesions. In advanced cases the intussusceptum is presum- 
ably necrotic. Under such circumstances dilatation sufficient to force back the 
intussusceptum can hardly fail to burst the intestinal wall. If the abdomen were 
immediately opened in all cases, the mortality would doubtless be very much 
diminished. In the hands of general practitioners and operators of no experience 
the chances of recovery are probably better if the patient be left to purely medical 
treatment, for a certain number of cases recover spontaneously after sloughing and 
separation of the intussusceptum. 
The operative treatment of intussusception consists (1) in the 
reduction of the invagination, (2) in resection and suture, and (3) in the 
formation of an artificial anus. The incision should be made preferably 
in the median line, unless the tumor, far to one side, requires for facile 
manipulation a cut directly over it. The situation of the lesion can usu- 
ally be detected by the presence of a tumor and by the tense mesentery 
dragged upon by the intussusceptum. If the integrity of the bowel is 
not impaired, gentle efforts at reduction should first be made. If these 
be unsuccessful after prolonged trial, resection of the invaginated por- 
tion well above and below the constricting and the constricted portions 
of intestine should be made. The mortality of the procedure, however, 
is so excessive that the advisability of palliation by the formation of an 
artificial anus above the constriction should be seriously considered, 
especially if the strength of the patient does not admit of the prolonged 
manipulations of resection and suture. 
Appendicitis, a condition of sufficient importance to receive distinct 
consideration in another part of this chapter, must nevertheless be 
enumerated here as a common cause of acute obstruction, which it pro- 
duces by means of the adhesions resulting from copious exudate of 
plastic lymph about a compromised appendix. These are the cases often 
masked by the co-existence of a generalized septic or putrid peritonitis. 
Volvulus.—In this rare form of acute obstruction the lesion may be 
produced by the revolution of a single coil about its mesentery or by 
the twisting together of two separate coils. An intestinal coil heavily 
loaded with faeces, hanging by a long mesentery, presents the most 
favorable condition for a twist. The most common seat of the lesion 
is the sigmoid flexure, where it is not unusual to find an enormously 
lengthened coil, which when distended stretches out in the form of a 
huge S from the left sacro-iliac synchondrosis to the liver, thence into 
the pelvis. Volvulus usually appears after middle life, and is four times 
as common in men as in women. 
In a second form the twist usually involves the sigmoid flexure and a loop 
of small intestine, though it may be confined to two loops of small intestine. A 
twist once formed is soon so fixed by adhesions as to become completely and perma- 
nently obstructed. 
Symptoms and Diagnosis.—The symptoms of volvulus usually 
come on suddenly. Pain, in this as in other forms of acute obstruc- 
tion, is an early, lasting, and important symptom. At first it is usually 
referred to the umbilicus, but later it becomes localized in the region of 
the lesion. If the twist be in the small intestine, vomiting is an early 
symptom; if in the large, a late one. The nature of the vomitus 
depends upon the seat of the obstruction ; if high up, there is early 
regurgitation of the contents of the small intestine into the stomach. 
Fecal vomiting is a late symptom when the volvulus is in the sigmoid INTESTINA L OBSTR UCTIONS. 
361 
flexure. Distention of the twisted coil is due to decomposition of its 
contents and passive congestion of its walls. If the patient lives long 
enough and the twist is not reduced, necrosis of the bowel-wall, with 
extravasation, takes place, whereupon the symptoms of general peri- 
tonitis appear. 
The course of the disease is violent and fatal if relief is not afforded 
by early operation. 
The diagnosis of volvulus cannot be made with certainty. If the 
symptoms of acute obstruction develop suddenly late in life in a patient 
habitually constipated, volvulus may be suspected. This suspicion may 
be strengthened by the detection of the ill-defined tumor of a distended 
and resistant intestinal coil. These symptoms, however, are present also 
in an intussusception ; the absence of bloody stools would indicate rather 
a volvulus. An absolute diagnosis can be made only by exploration. 
Treatment.—In the treatment of volvulus palliative measures are 
of no avail. By the time the formidable symptoms of acute obstruc- 
tion have become manifest the intestine is fixed in its abnormal position. 
External manipulations accomplish nothing, and enemata do more harm 
than good. The lesion is a mechanical one, like the twist of an ovarian 
tumor upon its pedicle, and demands immediate exploration. Unfortu- 
nately, the unavoidable delay before surgical relief can be applied is in 
most instances so great that the mortality after operation is very high. 
By the time the affected coil can be untwisted the constitutional depres- 
sion is extreme, especially in old people, and the local condition beyond 
remedy. If the bowel-wall be gangrenous or if the vessels be throm- 
bosed, either resection of the whole coil or formation of an artificial 
anus is demanded. In either case death is likely to follow. As soon 
as the diagnosis has been made the abdomen should be incised in the 
median line, or over the distended coil if it can be felt. The cut should 
be long enough to expose the lesion completely, and to permit not only 
a most thorough examination, but easy surgical manipulations. 
When the bowel is necrotic, the whole coil should be excised and immediate 
suture made if the patient’s condition permits so prolonged an operation. If 
haste be necessary, the cut ends of the bowel may be sewed into the abdominal 
wound. To prevent recurrence the mesentery of the affected coil may be short- 
ened by taking a tuck in it, (For the consideration of acute obstructions depend- 
ent upon embolism and thrombosis of the mesenteric vessels, see Surgery of the 
Mesentery.) 
Symptoms in General of Acute Intestinal Obstruction.— 
Symptoms of intestinal obstruction cannot be definitely divided into the 
acute and the chronic, because many forms of acute obstruction are 
dependent upon chronic disease. From the clinical point of view, the 
symptoms of obstruction may be divided into those which come on sud- 
denly without antecedent causes, and those which appear slowly as a 
gradually increasing obstruction or as intermittent acute attacks of 
greater and greater severity. The symptoms of acute obstruction due to 
chronic disease, especially carcinoma, are found on careful questioning 
to have been preceded, in most instances, by obscure symptoms of the 
original disease. 
Incomplete obstructions due to the pressure of bands, to internal incarcera- 
tions, and to similar mechanical lesions may exist for years without producing 
absolute stoppage of the intestinal stream. In such cases temporary obstruction 362 
SURGERY OF THE ABDOMEN. 
causes attacks of transitory colic which disappear spontaneously. Similarly a 
history of preceding attacks of pain is often elicited when acute symptoms sud- 
denly develop in the course of chronic obstructions dependent upon organic dis- 
ease of the intestinal wall. Serious apprehension may not have been aroused in any 
of these attacks. In most of the lesions causing acute obstruction no pre-existing 
symptoms dependent upon them could have existed. The symptoms of acute 
obstruction are pain, vomiting, diarrhoea, and distention, with a primary shock 
which varies in depth with the causative lesion. Constipation necessarily results. 
To the above cardinal symptoms of acute obstruction are added in 
the course of a few hours those dependent upon bowel-necrosis and 
local or general peritonitis. (See Volvulus, Intussusception, Internal 
Strangulation, Mesenteric Embolism and Thrombosis.) In simple 
obstructions unattended by bowel-necrosis—in kinks, bands, flexures, 
the pressure of tumors, and the impaction of foreign bodies, gall-stones, 
and enteroliths, the cardinal symptoms above enumerated alone exist, 
though they increase to an extreme degree, and persist until relieved 
mechanically. 
Diagnosis.—The diagnosis of the variety of the lesion is of great 
clinical importance; for practical purposes, however, it is necessary 
to know only that some lesion exists demanding interference. 
In acute mechanical obstructions constitutional signs are at first absent; peristalsis 
is increased; intestinal coils can be seen in contractions under the abdominal 
walls if they are thin ; no pre-existing cause can be found; distention is at 
first local, later general. In general peritonitis constitutional signs are present 
early; peristalsis is diminished, then absent; no intestinal movements can be 
seen or heard; a pre-existing lesion can generally be demonstrated ; distention is 
general. Common to both conditions are pain, vomiting, distention, shock. 
The pain of obstruction is paroxysmal; that of peritonitis, continuous. Vomiting, 
distention, and shock do not differ materially in the two lesions. 
In the later stages of those obstructive conditions which cause gangrene differ- 
entiation must depend upon the history only. Except in the rarest instances an 
exploratory diagnosis is demanded by the chief symptoms common to both obstruc- 
tion and peritonitis. 
The diagnosis between the different forms of obstruction, though of con- 
siderable importance, does not justify prolonged observation or the employment 
of time-taking methods. Between the lesions of internal strangulations, bands, 
kinks, and between acute and chronic lesions in general, the distinction is at 
times impossible. As a rule, however, one is able to say whether the symp- 
toms are due to a slowly progressing organic disease or to one of the acute 
varieties of mechanical obstruction. All acute obstructions come on suddenly, 
without previous symptoms. If acute obstructions occur in the course of chronic 
disease, a careful consideration of the history will bring out the fact, or will, at 
least, suggest it with some probability. Acute general peritoneal infection follow- 
ing the symptoms of acute obstruction suggests strongly those processes which begin 
in obstruction and end in gangrene. In intussusception and in volvulus certain 
characteristic signs appear—in the former bloody stools and a soft sausage-shaped 
tumor; in the latter, an obscure and resistant coil. 
Symptoms of intestinal obstruction due to the paresis of a local coil, 
as seen in mesenteric embolism and thrombosis, may be considered in connection 
with lesions causing acute mechanical obstruction. A clear distinction is often 
impossible. The history of the case, with the presence of tense and resistant coils 
and with symptoms of a general infection early in the course of the attack, 
strongly suggest vascular stasis in the mesentery. Yet in volvulus the bowel- 
necrosis may come on early as the result of such stasis, and the distended coils 
may be felt as resistant masses through the abdominal wall. As a rule, however, 
the symptoms in volvulus are less violent than those in mesenteric embolism or 
thrombosis. Pain is a subordinate symptom in the latter. 
Inflation of the rectum by gas or air may be employed as a diag- 
nostic measure in the course of the palliative treatment of intussus- INTESTINAL OBSTRUCTIONS. 
363 
ception and volvulus. In a general way, the seat of the obstruction if 
below the ileo-csecal valve can be determined. Forced injections beyond 
the ileo-csecal valve are hardly justifiable in view of the great danger of 
rupturing the intestine. In rare instances manual examination by the 
rectum may be employed for the determination of lesions low down in 
the sigmoid flexure. 
Treatment.—Surgical interference is indicated whenever an acute 
intestinal obstruction is suspected. When the nature of the lesion 
is beyond doubt the favorable period for intervention has usually passed. 
Surgical treatment, to be successful, must be applied in the earliest 
hours of the disease. The symptoms which demand exploration 
do not differ materially in most of the abdominal emergencies, whether 
the case be one of hemorrhage, of intestinal extravasation, of intestinal 
obstruction, or of any of the emergencies of pelvic disease. In acute 
abdominal lesions marked by pain, nausea, vomiting, and shock, with 
rigidity of the abdominal muscles, exploration is demanded. Though 
these symptoms may not invariably be caused by a grave lesion, in the 
majority of cases they are due to some mortal complication. The symp- 
toms of later stages—distention, obstipation, stercoraceous vomiting, 
collapse—though they may justify interference, do not encourage it, 
from the mortality of operations at this stage. It is a question, indeed, 
whether in those cases in which death is clearly impending the surgeon’s 
duty requires him to interfere. Nevertheless, inasmuch as a rapid ex- 
ploration, with formation of an artificial anus, sometimes succeeds in these 
desperate conditions, exploration is probably the best course to pursue 
unless the patient is actually dying. 
Palliative treatment in acute intestinal obstruction is justifiable only in excep- 
tional conditions, for the mechanical causes present in the great majority of cases 
demand a mechanical remedy. The possible exceptions are intussusception, vol- 
vulus, and impactions low down in the intestine. By the spontaneous efforts of 
nature intussusceptions may be thrown off, twisted coils may be untwisted, im- 
pacted bodies maybe detached. Abdominal taxis and massage in these conditions 
may assist spontaneous efforts at relief. In no other forms of intestinal obstruc- 
tion, whether acute or chronic, do palliative measures offer reasonable hope of cure. 
When exploration has been determined upon, the abdomen should 
be immediately opened—in obscure cases in the median line above 
or below the umbilicus, or in clear cases over the seat of the lesion. A 
short incision should be made at first through the peritoneum to deter- 
mine, by the escape of serum, pus, fecal matter, or blood, whether some 
serious lesion is present. The operator, in full confidence that he is on the 
right track, may then enlarge the incision enough to permit manual 
examination of the whole abdominal cavity. The subsequent manipu- 
lations will depend upon the lesion found. Acute obstructions should 
be treated radically if the patient’s strength justifies prolonged opera- 
tion. (See Special Causes of Acute Obstruction.) If haste be essential, 
an artificial anus (enterostomy or colostomy), a temporary measure, may 
rapidly be made; radical intervention may be practised later. Bands 
must be divided ; strangulations, intussusceptions, and twists reduced ; 
necrotic bowel either excised or fastened into the wound and opened. 
The excessive distention usually present in acute obstructions and in 
general peritonitis seriously embarrasses both exploration and radical 364 
SURGERY OF THE ABDOMEN. 
operation. To relieve such distention the distended coils may be aspi- 
rated or iiicised. 
The teeatment of the peritoneum after radical or palliative ope- 
ration is usually that of general peritonitis. If, however, no general 
peritonitis be present, and if the peritoneum has escaped infection dur- 
ing the operation, neither general irrigation nor extensive cleansing is 
necessary. Indeed, both are objectionable, because they add to the shock, 
as well as to the danger of spreading a local contamination. (See 
Treatment of General Peritonitis.) 
The peognosis in all forms of acute obstruction is grave; it is espe- 
cially serious in those lesions attended by necrosis of the bowel-wall and 
general peritonitis. Obstructions due to impactions, bands, and internal 
strangulations are more favorable than those due to intussusception 
and volvulus, embolism and thrombosis. All forms of acute intestinal 
obstruction, relieved in the first few hours of the attack, have a prog- 
nosis by no means unfavorable. As soon as death of the bowel-wall 
takes place and general infection develops, the mortality under any 
method of treatment is excessive. 
Chronic Intestinal Obstruction.—Chronic obstruction to the intes- 
tinal flow results from : 
(1) The growth of tumors which involve the intestinal wall (carci- 
noma, sarcoma, and fibroma) ; 
(2) Cicatrized and contracted tubercular, typhoidal, diphtheritic, 
dysenteric, and syphilitic ulcerations ; 
(3) The pressure of external growths and inflammatory masses ; 
(4) Fecal impactions; 
(5) Ileus paralyticus of the insane. 
Interference with the flow of the intestinal stream may also occur 
intermittently in those lesions which at times suddenly produce com- 
plete stoppage—an intermittent or recurring intestinal obstruction. This 
condition may occur when kinks, flexures, or bands are present, when 
internal incarceration exists, when a tumor growing from the internal 
wall becomes temporarily impacted, the impaction ceasing as soon as the 
intestinal spasm subsides. Chronic intestinal obstruction from organic 
disease in the great majority of cases is due to stricture of the intestinal 
lumen. Occasionally, though very rarely, the obstruction results from 
an outside pressure which does not involve the lumen. Organic stric- 
tures may be caused by carcinoma, tuberculosis, and benign neoplasms. 
The last are very unusual. They may be fibrous polyps, cysts, or 
lipomata. Tuberculosis of the intestinal wall is occasionally seen. 
Carcinoma, by far the most common cause of organic stenosis, is 
situated most frequently at the sigmoid flexure; less frequently at the 
ileo-csecal valve and at the hepatic and splenic flexures. The disease 
may be annular and limited to the inner layers of the intestine, or it may 
penetrate early the peritoneum and involve adjacent coils. Metastasis 
through the lymph-channels is usually slow. The causes of intestinal 
cancer are unknown. They probably do not differ from those of cancer 
elsewhere. The disease has been known to start in the cicatrices of 
intestinal ulcers and in the inflammatory thickenings about impacted 
foreign bodies. 
The cancerous tumor may be a narrow ring or a broad fusiform mass INTESTINAL OBSTR UCTIONS. 
365 
involving the internal layers only of the intestine and constricting its 
lumen; it may involve all the layers and contiguous coils as well. 
Starting from the internal surface, it may project into the lumen and fill 
it with a fungous and ulcerating mass (Fig. 164). The tumor may be 
Fig. 164. 
Cancer of intestine obstructing the lumen. Above the constriction the bowel is enormously 
dilated and its wall thickened (Warren Museum). 
imperceptible by palpation or it may be conspicuous to touch and sight. 
In some cases the tumor cannot be felt because of its situation; in 
others, because of its nature. The tumor may be fusiform, oval, or flat- 
tened, smooth or irregular; of varying degrees of density, though usu- 
ally hard. It may be freely movable or firmly fixed. It may be dull 
or tympanitic—dull if in the anterior wall; tympanitic if in the poste- 366 
SURGERY OF THE ABDOMEN. 
rior and covered by a distended portion of bowel. The internal surface 
maybe ulcerated, friable, and bleeding, or projecting, smooth, and indu- 
rated. The lumen may gradually become entirely closed, and later be 
re-established by ulceration. As soon as the peritoneum is extensively 
affected serum is exuded; ascites may be excessive. 
The course of intestinal cancer is gradually progressive. The dis- 
ease invades viscera both contiguous and remote; a general cachexia 
develops; death takes place from exhaustion. In other cases intestinal 
perforation with fecal extravasation causes general peritonitis and death. 
In rare instances localized peritonitis and abscess develop. 
The symptoms of intestinal cancer are those of the disease itself, 
combined with those of obstruction, perforation, and extravasation. In 
the majority of cases intestinal obstruction is present; in a few, per- 
foration and peritonitis. The symptoms of cancer of the intestine are 
usually unsuspected until obstruction takes place or a tumor is dis- 
covered. An occlusion almost total may have been preceded by no 
symptoms whatever; the impaction of a grape-seed may cause the very 
first symptom. Careful inquiry may show a previous loss of weight, 
an indefinite malaise, an occasional colic. Advanced cases show the 
characteristic cachexia of cancer. Pain from the growth itself is rare ; 
from paroxysmal intestinal efforts to overcome the obstruction it is the 
rule. The tumor is usually tender. 
The symptoms of cancerous obstructions are either acute or chronic 
and intermittent. The former, being dependent upon simple obstruc- 
tion, are unaccompanied by the symptoms of bowel-necrosis. (For 
changes in the bowel-wall above constriction, and for symptoms of 
chronic obstruction in general, see Pathology and Symptoms of Chronic 
Obstruction.) 
Diagnosis of Cancer of the Intestine.—Cancer of the intes- 
tine must be distinguished from benign neoplasms and from benign 
strictures, from lesions outside the intestine causing obstruction, and from 
incomplete obstruction by bands and incarcerations. 
The diagnosis is generally easy. The symptoms are progressive. 
A gradual impairment of health and loss of weight, preceding obstruc- 
tive symptoms in patients at or beyond middle life, suggest the pos- 
sibility of cancer; a marked cachexia strengthens the diagnosis; a hard 
movable tumor, with ascites, confirms it. Yet the lesion may not be 
cancer. Exploration alone will decide the question. In the absence of 
a tumor the diagnosis must be in a measure doubtful, though obstruc- 
tion in an adult preceded by loss of weight alone is sufficient evidence 
in the majority of cases to warrant the diagnosis. 
In strictures of benign origin the health is unimpaired, cachexia is 
absent, the symptoms are not, as a rule, progressive. Even in cicatricial 
strictures and in pressure obstructions the patient lives for months or 
years in comparative comfort. 
The treatment of intestinal cancer is (1) medical and palliative— 
to keep up the strength (food and tonics); to allay obstruction (opiates, 
liquefaction of faeces); (2) operative—excision of the disease; end-to-end 
suture with anastomosis ; artificial anus. 
Obstructive symptoms are best allayed by opiates, which relieve spasm and 
proximal pressure. Small doses of opium or morphine will often produce evacua- INTESTINA L OBSTIl UCTIONS. 
367 
tions when cathartics will prevent them. Liquefaction of faeces, always present 
above chronic obstructions, may be augmented by the avoidance of coarse food, 
seeds, etc. 
Whenever possible the disease should be thoroughly excised. Repair must be 
made according to circumstances—end-to-end suture if possible or closure of the 
resected ends and lateral anastomo- 
sis. (See Operations on the Intes- 
tine.) 
The successes reported after com- 
plete removal early in the disease 
encourages the hope of permanent 
cure. When radical removal is im- 
possible, lateral anastomosis should 
be performed. An artificial anus 
should be made in those rare in- 
stances only in which the proximal 
and distal coils cannot be brought in 
contact. 
Sarcomata of the intestinal 
Avail are rare, though occasion- 
ally seen. They occur at all 
ages, but most frequently in the 
young. They are usually sec- 
ondary. More rapid in growth 
than carcinomata, they present 
the same symptoms. A tumor 
can generally be felt. Palliative 
and radical treatment do not 
differ from that of cancer, though 
radical removal is possible only 
in primary cases. 
Stenoses resulting from cica- 
tricial contractions after intes- 
tinal ulcers, tubercular, typhoidal, 
syphilitic, and diphtheritic, pre- 
sent the symptoms of gradually 
increasing obstruction (Fig. 165). 
Typhoidal and tubercular ulcers 
are usually situated in the small intestine; diphtheritic (dysenteric), in 
the large; syphilitic, at the rectum. 
Cicatricial stenoses, like cancerous, may not be suspected until the 
lumen is extremely small. Transitory colics result from a narrowing 
which requires unusual peristaltic effort. The general health is unaf- 
fected. Complete obstruction may come on suddenly from impaction of 
a seed or other solid particles. 
The treatment should be radical in all cases—by excision with 
suture or anastomosis or by enteroplasty. Artificial anus need never be 
employed ; anastomosis at one point or another is always possible. 
External pressure from neoplasms or inflammatory masses should 
be suspected whenever obstructive symptoms arise in the presence of 
abdominal tumors and inflammatory exudations, the nature of which is 
obvious. 
Chronic obstructions occasionally occur as the result of the impaction 
of hardened fecal masses in the ascending or the transverse colon. This 
Fig. 165. 
Stricture from cicatrized tubercular ulceration 
(Warren Museum). 368 
SURGERY OF THE ABDOMEN. 
condition is most frequent in constipated old women. Fecal masses 
simulating hard, nodulated, and movable tumors can often be felt through 
the thin abdominal walls. Serious mistakes in diagnosis may occasion- 
ally be made in this condition. 
Ileus paralyticus is due to the paralysis of the muscular coats of 
the intestine. The possible occurrence of this lesion should be borne in 
mind in the presence of chronic obstructive symptoms in the insane. 
Fecal Fistula and Artificial Anus. 
An artificial anus is an abnormal opening in any part of the abdom- 
inal wall through which all the contents of the bowel escape. The 
opening in the bowel is made after securing it to the abdominal wall. 
An intestinal fistula is an opening through which only a part of the 
intestinal contents escapes. Intestinal fistulae may be external or in- 
ternal. An external intestinal fistula is a direct opening from any 
portion of the intestine through the abdominal parietes. An internal 
intestinal fistula is a communication between the intestinal tract and the 
the bladder, the stomach, the vagina, the gall-bladder, the pleura, or the 
lungs, or between contiguous intestinal coils. 
Etiology.—An artificial anus is practically always intentional, made 
for the relief of surgical emergencies or chronic obstructions. Intestinal 
fistulae are always accidental, and may be caused by 
(1) Penetrating and lacerated wounds and ruptures of the intestine; 
(2) Perforation of the intestine by typhoidal, syphilitic, and tuber- 
cular ulcerations, by the necrosis and gangrene of internal 
strangulation, by foreign bodies, and by malignant disease; 
(3) Intestinal actinomycosis; 
(4) Rupture of appendicular or other pelvic or abdominal abscesses; 
(5) Injury to the intestine in the course of abdominal operations; 
(6) The giving way of ligatures or sutures; 
(7) The pressure of drainage-tubes. 
The ulcerations that most frequently terminate in intestinal fistulae are of the 
tubercular variety. Foreign bodies, gall-stones, enteroliths, or fragments of bone 
may make their way out of the abdomen through adhesion-formation, abscess, and 
external perforation. Malignant disease, complicated with septic infection and 
suppuration, is a not uncommon cause of intestinal fistulae. Actinomycosis occa- 
sionally results in abscess, intestinal perforation, and fistulae: it occurs most fre- 
quently in the ileo-caecal region. The most common causes of external and in- 
ternal intestinal fistulae are pelvic and abdominal abscesses. 
The majority of intestinal fistulae close spontaneously sooner or later. 
Those that may be reasonably expected to close under palliative treat- 
ment are the ones in which the opening in the bowel is small, not due 
to tubercular or malignant disease or actinomycosis, and in which the 
fistula is not lined with intestinal mucous membrane. Internal intes- 
tinal fistula? in the majority of cases cause no symptoms. 
The surgical treatment of intestinal fistula} consists in— 
(1) Stimulation and cauterization of the fistulous tract and free 
drainage of the abscess-cavity, with or without curetting; 
(2) Disinfection and suture of the fistulous tract, without opening the 
peritoneal cavity; METHODS OF INTESTINAL SUTURE. 
369 
(3) Complete excision of the fistulous tract and intestinal resection 
or anastomosis. 
The risks in the radical operation are considerable. The mortality has been 
high, because of the difficulty of preventing contamination of the general peri- 
toneal cavity. When the fistulous opening is so high up in the small intestine 
that the nutrition of the patient is seriously impaired operation should be per- 
formed as soon as possible. On the other hand, cases in which the nutrition is not 
interfered with should be treated for many months by the simpler methods before 
resorting to intestinal resection or anastomosis. 
Closure of an artificial anus should be accomplished by complete 
freeing of the intestine, with resection of the fistulous opening and 
suture. The adherent coil should be completely separated and drawn 
out of the wound. The fistulous opening can then be carefully and 
thoroughly excised; the freed coil will permit satisfactory approxima- 
tion of the refreshed edges. After suture the coil may be returned to 
the abdominal cavity and the external wound closed, a small strand of 
gauze being left for security against extravasation. 
Methods of Intestinal Suture 
(For the history and development of intestinal suture methods the 
student is referred to larger works on surgery.) The correct principle 
of uniting intestinal wounds was not determined until 1825, when 
Lembert taught the necessity of approximating serous surfaces to serous. 
Since then a multitude of sutures and mechanical devices have been 
brought forward, only a few of which have stood the test of practical 
use. Those most used at the present time are— 
(1) The Lembert suture in its different forms; 
(2) Czerny-Lembert suture ; 
(3) Halsted’s quilted suture ; 
(4) Cushing’s right-angled suture ; 
(5) Senn’s bone plates ; 
(6) The Murphy button. 
The approximation of serous surfaces to serous is accomplished by 
passing the sutures in and out of the intestinal wall at right angles to 
the line of proposed union and a short distance from it (Fig. 166). 
The needle pierces the peritoneal, muscular, and sub- 
mucous coats, but does not enter the mucous. When 
the needle strikes the submucosa a sudden resistance 
is encountered by which the layer is recognized. A 
narrow portion of the submucosa is caught by chang- 
ing the direction of the needle, which thence is 
brought out of the intestinal wall, carried across to 
the opposite intestinal surface, where the process is 
repeated. Tying the sutures inverts the edges of 
the intestine and approximates the serous surfaces. 
(1) The Lembert suture may be applied either as 
an interrupted or a continuous stitch. (See Fig. 167.) 
It has the advantages of simplicity and rapidity. 
(2) The Czerny-Lembert suture differs from the preceding in that a 
preliminary set of interrupted stitches is applied to the mucous mem- 
brane. 
Fig. 166. 
Diagram of Lembert 
suture. 370 
SURGERY OF THE ABDOMEN. 
(3) Ilalsted’s suture applies the Lembert principle to the plain 
quilted stitch. 
(4) Cushing’s right-angled suture is a continuous quilted suture. 
Fig. 167. 
Application of the interrupted Lembert suture. 
Senn’s bone plates and the Murphy button are the two mechanical 
aids to intestinal anastomosis and suture most widely known and used. 
(5) Senn’s plates, composed of decalcified bone, have been used for 
making rapid anastomosis between hollow viscera. In the viscera to 
be approximated, suitable incisions are made, into which the plates are 
slipped. They are then fastened into position by transfixing the walls 
of the bowel with the needles and tying the threads. Additional inter- 
rupted stitches may be used for greater security. 
(6) The Murphy button is a recent mechanical device, the construc- 
tion of which will be seen in the accompanying figure (Fig. 168). It 
Fig. 168. 
The Murphy button. 
can be used with rapidity and accuracy in end-to-end union and in 
lateral anastomosis. The two portions of the button are first secured 
by purse-string sutures in the coils to be united, which are then approxi- 
mated as shown in Figs. 169, 170. Union of the peritoneal surfaces OPERATIONS ON THE INTESTINE. 
371 
results; the button is released in from ten to twelve days by sloughing 
of the included tissues and passed per anum. 
Fig. 169. 
End-to-end union of intestine by means of the Murphy button: the two portions of the Murphy 
button, held in position by purse-string sutures, are ready to be pressed together. 
Wounds of the intestine may be closed by either the Lembert, the 
Halsted, or the Cushing suture in a single or a double row. End-to- 
Fig. 170. 
Union—end to end—with the Murphy button. 
end union or lateral anastomosis may be performed by the use of sutures 
alone or by the aid of Serin’s bone plates or the Murphy button. If 
time permits, union by the application of the Lembert or Halsted suture 
is far preferable to that by mechanical contrivances. When the condi- 
tion of the patient demands speed, it is best to use either the plates or 
the button as may seem preferable to the individual operator. Serin’s 
plates are used only in anastomosis; Murphy’s button, iir anastomosis 
and in end-to-end approximation. 
Operations on the Intestine. 
The principal operations on the intestine are—resection, anastomosis, 
enterotomy, enterostomy, and enteroplasty. 
Intestinal resection is demanded— 
(1) Whenever the vitality of the bowel is seriously impaired by 
injuries, internal or external strangulation, mesenteric 
embolism or thrombosis; 372 
SURGERY OF THE ABDOMEN. 
(2) In intussusception and volvulus; 
(3) For restoration of the lumen in cases of benign stricture and 
for extirpation of tumors and malignant disease ; 
(4) For the cure of fecal fistulae. 
Most of the lesions demanding resection involve the small intestine, although 
the seat of intussusception and volvulus is usually the large intestine. 
Previous to resections of the intestine the bowel should be empty whenever 
possible, for manipulations are thus facilitated and the danger of fecal escape and 
of peritoneal infection are minimized. Excepting in acute emergencies and chronic 
obstructions, in which the distended bowel above the obstruction cannot be 
reached, the intestines may be emptied by rectal enemata and by the use of 
cathartics and liquid food for twenty-four or forty-eight hours before the opera- 
tion. Preliminary washing out of the stomach may also be employed. 
The incision through the abdominal wall should be made long enough 
to permit free delivery of the diseased intestinal coil. Operative manip- 
ulations should be as far as possible outside of the peritoneal cavity, 
which should be protected thoroughly by gauze packing. Great 
distention in the intestinal coil may be relieved by aspiration or 
by incision. (See Peritonitis.) Compression of the bowel above and 
below the diseased portion may be effected by the fingers of an assistant 
or by mechanical aids—rubber bands and clamps. Digital compression 
is preferable. The seat of the disease should be completely excised, the 
mesentery being tied in sections. Suture of the divided bowel should 
begin at the mesenteric border. It is at this point that the greatest care 
must be taken to make the joint tight. Excision of a V-shaped piece of 
mesentery may be necessary before the application of the stitches. 
After the mesenteric border has been thoroughly secured application of 
the remaining sutures may be made in any order, provided that the 
inverted edges are brought securely together. Any one of the methods 
of intestinal suture previously described may be used, according to the 
Fig. 171. 
End-to-end suture after the application of interrupted Lembert stitches. 
preference of the operator. The interrupted Lembert is undoubtedly 
the best and the one generally employed. The manner of applying the 
stitches and of securing the mesentery will be seen in the accompanying OPERATIONS ON THE INTESTINE. 
373 
diagram (Fig. 171). If time permit, a second row of interrupted sutures 
may be used, though in the majority of cases this procedure is not neces- 
sary for safety; moreover, by inverting too broad a margin a constrict- 
ing ring may be produced in the lumen of the gut. 
If the condition of the patient is such as to demand extreme rapidity in opera- 
tive technique, no better method can be employed than the use of the Murphy 
button, as shown in the diagrams (Figs. 169,170). Lateral anastomosis, after resec- 
tion and closure of the divided ends, possesses no advantage over end-to-end union 
by suture. The operation cannot be done any more rapidly; peristalsis is inter- 
fered with; the course of the fecal stream is abnormal; and the lateral opening 
always contracts. When the condition of the patient will not permit end-to-end 
union by suture or even by the use of the Murphy button, an artificial anus should 
be made, and secondary suture performed at a subsequent and more favorable 
time. After intestinal resection and suture a strand of gauze should be left in 
contact with the line of sutures to provide against the giving way of a stitch with 
extravasation and peritonitis, the principal cause of death after this operation. 
The strand of gauze should emerge from the lower angle of the abdominal wound, 
and the wound itself be almost entirely closed. The gauze should be removed at 
the end of forty-eight hours. 
Intestinal Anastomosis.—Portions of the intestinal tract more or 
less distant from each other may be united by lateral intestinal anasto- 
mosis, an expedient by which the intestinal stream is diverted around 
some obstacle to its flow. The procedure is indicated (1) in lesions of 
the intestine too extensive for free excision and end-to-end suture; (2) 
Fig. 172. 
Lateral anastomosis: first stage of the operation. 
in cases demanding haste. Anastomoses between the stomach and the 
intestine are indicated in pyloric obstructions too extensive for resection. 
In the field of gastro-enterostomy the principle of lateral anastomosis is 
most useful; in many instances it affords the only prospect of relief. 374 
SURGERY OF THE ABDOMEN. 
Lateral anastomosis may be performed with sutures alone or by mechanical 
devices. When performed by means of sutures alone, a longitudinal cut is made, 
two or three inches in length, through the coils to be united. The incision should 
be made opposite to the mesenteric attachment (Fig. 172). The posterior edges 
are first brought together by means of a continuous or an interrupted stitch. The 
margins of the cut may be sewed over and over before uniting them. The anterior 
edges are next united by another continuous stitch. Finally, for additional security, 
a second line of interrupted or continuous sutures may be applied (Fig. 173). 
Fig. 173. 
Lateral anastomosis: operation finished. 
The disadvantage in the use of sutures alone is the time required. The objection 
to the use of mechanical devices in general is the insufficient size of the anastomotic 
opening and the great danger of secondary contraction ; to the use of the Murphy 
button, in particular, the danger of extravasation and of the impaction of the button 
itself. To prevent closure by contraction the intestinal opening should be as large 
as possible. Intestinal anastomosis is generally made between intestinal coils 
above and below a constricted portion. 
Enterostomy is the formation of a permanent opening into the intes- 
tine ; the term is usually restricted in its use to such operations upon the 
small intestine. It is an emergency operation, demanded for the tem- 
porary relief of acute intestinal obstruction; it is not to be employed if 
the strength of the patient justifies radical procedures. Enterostomy 
differs from the formation of an artificial anus only in that it usually 
involves the small intestine. The operation consists simply in incising 
the bowel after it has been sutured to the abdominal wound. The objec- 
tion to the operation is that if the opening be made too high in the small 
intestine, the nutrition of the patient is seriously impaired. Notwith- 
standing this, enterostomy, even high up in the small intestine, may be 
successful in tiding the patient over the immediate dangers of an acute 
obstruction, so as to permit radical treatment of the disease later. DISEASES OF THE VERMIFORM APPENDIX. 
375 
Jejunostomy for purposes of feeding is a form of enterostomy occa- 
sionally necessary as a substitute for gastrostomy in cases of malignant 
disease of the pylorus and neighboring structures so extensive that 
neither resection nor anastomosis is feasible. The operation has been 
performed but seldom. In the execution of this procedure care must be 
taken not to interfere with the excretion of the bile and the pancreatic 
juice. 
Enteroplasty is an intestinal operation exactly similar in its tech- 
nique to pyloroplasty. (See Operations on the Stomach.) By this 
procedure fibrous strictures of the intestinal wall are overcome without 
resection of the gut. Through the tissues of the stricture a diamond- 
shaped incision is made which is sutured transversely. Opportunity for 
such an operation seldom arises, however. 
Excluding possibly pelvic inflammations in the female, appendicitis 
in its various forms is the most common surgical affection of the abdo- 
men. In males it is by far the most important. 
Anatomy.—The vermiform appendix is attached to the caecum near the 
insertion of the ileum. The base of the appendix arises at the beginning of 
the longitudial striae of the large intestine. It is attached to the ileum by a 
mesentery which varies in length, breadth, and thickness. The blood-supply is 
from the ileo-colic branch of the superior mesenteric artery. In females a branch 
to the appendix from the ovarian artery occasionally furnishes an additional blood- 
supply—a fact which may account for the comparative infrequency of appendicular 
necroses in women. The base of the appendix is constant, moving with the move- 
ments of the caecum; its extremity may point in any direction. The normal 
situation of the appendix, therefore, varies between extreme degrees. It depends, 
first, upon the position of the caecum itself, and, secondly, upon the length and 
direction of the appendix. In most cases the caecum is movable and the base of 
the appendix easily accessible; occasionally the caecum is fixed deep in the iliac 
fossa or is turned upon itself, carrying the base of the appendix sometimes as high as 
the right kidney. The main body of the appendix may float among the intestines, 
pointing in any direction; it may be deep in the pelvis, between the rectum and 
the bladder or (in the female) between the rectum and the uterus; it is often retro- 
caecal; not infrequently the tip is in the loin, and it has been found also in contact 
with the liver. The appendix is sometimes situated in a fossa of the peritoneum 
behind the caecum. It has been found in extraordinary positions—in a scrotal or 
umbilical hernia or at the extreme left of the pelvis. These peculiarities of situa- 
tion have an important bearing upon the symptoms, cause, prognosis, and even the 
etiology, of appendicitis. 
The vermiform appendix varies in length, in weight, in calibre, and in size. 
Ordinarily it is about the length of the little finger; it may be six or eight inches 
long. It is rarely, if ever absent. It has a mucous, muscular, and peritoneal coat. 
The middle layer, rich in adenoid tissue, is prone to septic infection. The appen- 
dix contains numerous solitary follicles. The lumen of the appendix varies in 
size. Not infrequently it is constricted near the caecum. It is sometimes con- 
siderably dilated at the tip, and the organ has a club shape. The normal appendix 
is smooth and glistening, pinkish in color, and generally without visible blood- 
vessels. It is soft; rolled between the fingers, it gives no special sense of resistance. 
It is freely movable in all directions, and can be bent upon itself without fracture. 
The most important structural fact is the great thickness of the adenoid layer. 
The vermiform appendix has muscular fibres and a peristalsis of its own. 
Vermicular action is often observed. It shrinks in length very noticeably after 
removal from a living subject. 
DISEASES OF THE VERMIFORM APPENDIX. 
Etiology.—Appendicitis is a very common disease. It occurs much 376 
SUEGEBY OF THE ABDOMEN. 
oftener in males than in females. No age is exempt from it; it has been 
seen in a child of two and in a man of eighty. It is seen most frequently 
in the early years of life. Excluding deaths from certain zymotic dis- 
eases, deaths from appendicitis exceed in number those from any other 
acute abdominal lesion. It is by far the most common cause of peritonitis 
in the male, and it is not an uncommon cause in the female. There are 
no recognized conditions predisposing to appendicitis. Though it not 
infrequently occurs in the course of diarrhoea, it is seen quite as fre- 
quently in persons of constipated habit. The etiology is obscure. 
Pathology.—The inflammatory changes of appendicitis usually 
begin in ulcerations of the mucous membrane, through which micro- 
organisms make their way into the adenoid tissues. A necrosis ensues 
which may be limited in depth, length, and width; a small area may be 
involved or the whole organ may become gangrenous. Invasion of the 
peritoneum may cause a localized septic peri-appendicitis; sloughing ot 
the necrotic area may result in perforation and extravasation. Ulcera- 
tion of the mucous membrane may be caused by the pressure of fecal 
concretions or of foreign bodies, though foreign bodies are rarely met 
with. Smooth, hardened fecal masses, varying in size from that of 
a white bean to that of an olive, are found in the great majority of cases 
of gangrenous appendicitis. In some instances, however, no such cause 
is found. Pathological changes in the mucous membrane of the appen- 
dix are often associated with similar lesions in the mucous membrane 
of the caecum, and are doubtless often dependent upon them. In 
a considerable number of perforative inflammations no local cause can 
be found. In all acute gangrenes of the appendix the afferent artery, 
a terminal without anastomoses, will be found thrombosed—it will 
not bleed when cut. In fully-established necroses the gangrenous pro- 
cess extends from the interior to the surface. The width of the 
necrotic area is generally larger on the internal than on the external 
layers. In many instances the process will be found limited to the 
mucous and adenoid layers; as a rule, however, all the layers will be 
found affected. Very frequently the process goes on without symptoms 
until the peritoneal coat becomes involved ; hence in many cases the very 
first symptom is that caused by an infection of the peritoneum—an 
infection which varies from that of a minute bacterial invasion to a 
rapid and extensive fecal extravasation. The necrotic area may be 
situated anywhere in the appendix. (Vide Plate IX.) 
The course and the prognosis of the disease depend largely upon 
the exact seat and size of the perforation. As a rule, when the perfora- 
tion is situated at the tip, extravasation is sloiv and the peritonitis localized ; 
when at the base, extravasation is rapid and the peritonitis general. The 
rapidity of the extravasation depends also upon the size of the appen- 
dicular lumen and upon the amount and liquidity of the csecal contents. 
In some instances the necrotic process is so near the caecum that a por- 
tion of its wall is involved. This complication, though extremely rare, 
is as a rule rapidly fatal. Sometimes the whole appendix, with its 
mesentery, is gangrenous. In general as well as in limited necroses of 
the appendix a local and limited peritoneal infection begins as soon as 
the peritoneum is threatened—a general fulminating infection when the 
necrotic area gives way and intestinal fluids burst forth. Chronic infec- PLATE IX. 
Illustrating various degrees of involvement of Appendix Vermiformis. (Richardson.) 
A. Chronic, recurring. 
B. Ditto, much thickened. 
C. Acute, with necrosis and rupture. 
D. Showing local necrosis. 
E. Gangrene and perforation permitting fie cal extravasation. 
F. Total gangrene without perforation. DISEASES OF THE VERMIFORM APPENDIX. 
377 
tioiis processes, limited chiefly to the mucous and adenoid layers, result 
in the usual catarrhal changes in the former, with more or less thicken- 
ing of the latter. A general thickening, with an increase of weight, 
results. Such an appendix is resistant, friable, and deeply injected; 
it can easily be recognized by the finger. Wherever it may be situated 
in the abdomen, it may sometimes even be detected by palpation through 
the abdominal wall. The omentum in acute appendicitis, in a large 
proportion of cases, will be found in contact with the diseased appendix ; 
sometimes wrapped about it. It is often thickened, reddened, and 
necrotic. 
Cultures in acute appendicitis show almost invariably the colon bacillus alone ; 
in appendicular abscess of long standing, a mixed infection. (See Peritonitis.) 
The colon bacillus is found in the peritoneum about the appendix, in the layers 
of the appendix itself, and in its interior. The latest observations seem to show, 
however, that many intestinal organisms are present in this disease. 
Acute inflammations of the appendix which affect its peritoneum result 
almost always in peritonitis, either localized or general. The same bacteri- 
ological element probably exists in both, the difference being one of 
degree. 
When the perforation, from its size or its position or from any other 
reason, causes a rapid fecal extravasation, the infection is usually gen- 
eral ; when slow, local. In other words, the extent of the infection 
depends largely upon the power of the peritoneum in a given case to 
form barriers against spreading inflammation. In many chronic lesions 
of the appendix the peritoneal layer is unaffected and no adhesions 
whatever exist. Occasionally a long-continued though mild type of in- 
flammation results in extensive adhesions—sometimes of cartilaginous 
firmness. In the so-called obliterative appendicitis the ulceration and 
gangrenous process result in cicatricial contractions by which the lumen 
is partially or entirely obliterated. Such an appendix maybe contracted 
throughout its extent, or it may be club-shaped—cicatricial contractions 
separating the distal end from the caecum. The tip under such circum- 
stances is often distended by the secretions of a mucous surface which 
has no outlet—an appendicular cyst, the contents of which are often 
sterile from long encapsulation. 
An appendix, the seat and centre of recent inflammation, of which the products 
have been absorbed, often contains cheesy, friable, or grumous masses. Such an 
appendix is easily torn by the fingers or the instruments. In the course of time 
such evidence of recent infection disappears and the changed tissues become the 
seat of firm cicatrices. Remote pathological changes after acute appendicular 
inflammation are seen in cords and bands, which sometimes produce in the intes- 
tines an acute obstruction. In rare instances the appendix has the usual appear- 
ance of tubercular infiltration. 
Symptoms.—The first and most important symptoms of appendicitis 
are pain and vomiting, which, in the vast majority of cases, are the only 
symptoms in the first fiwv hours of the attack. The subsequent symp- 
toms are those of a localized or of a general peritonitis. Pain usually 
begins in the region of the umbilicus or in the epigastrium. It is soon 
accompanied by tenderness, and both become localized in the right iliac 
fossa or wherever the appendix may be situated. The pain is at first 
paroxysmal—later, constant. The temperature and pulse rise. Chill is 
rarely observed in the beginning of the attack, or, in fact, at any time 378 
SURGERY OF THE ABDOMEN. 
during the course of the disease. The objective signs are either negative 
or they are those of a localized or of a general peritonitis. Sharp inflam- 
mations, not attended by extravasation, show no further symptoms than 
those already described. The pain and tenderness gradually subside; 
there is neither dulness nor tumor; the appendix can seldom be felt; 
the constitutional symptoms disappear; and in the course of a few days 
the patient is able to leave his bed. When by perforation the contents 
of the appendix or of the caecum escape, the symptoms of a localized or 
of a general peritonitis ensue. (See Peritonitis.) Dulness and tumor 
are present if the inflammation and effusion are localized and near the sur- 
face. Such inflammations, however deeply situated, give no external 
signs whatever. When the lesion is deep in the pelvis, tenderness and 
tumor will sometimes be detected by rectal examination; when high up 
above the caecum, tenderness and dulness are noticeable in the right 
flank ; when at the usual seat of the appendix, at a point halfway between 
the anterior superior spine of the ilium and the umbilicus. The absence 
of tenderness in this definite spot by no means precludes the possibility 
of an appendicitis. The constitutional signs of infection gradually sub- 
side as the infection becomes limited by adhesion-formation. The physi- 
cal signs of abscess become more and more pronounced as the collection 
of pus increases in size. A distinct tumor can be felt early in superficial 
cases, late in those deeply placed. 
Collections of pus near the rectum often encroach upon that canal, and some- 
times break into it. They can be readily detected by the finger. Localized abscesses 
in the flank may come in contact with the liver; they may break through the fora- 
men of Winslow and infect the lesser omental cavity; they may extend between 
the liver and the diaphragm (subphrenic abscess), and may perforate the pleura, or 
even the lung. It is extremely rare, however, for pus to perforate the abdominal 
wall. Left to themselves, fecal abscesses of appendicular origin either break into 
the peritoneal cavity and produce an immediate and fatal general infection, or 
empty themselves into the intestine, the bladder, or the vagina. 
Diagnosis.—The diagnosis of acute appendicitis is rightly regarded 
as easy. Chief among the lesions to be differentiated from appendicitis 
are perforations of other portions of the alimentary canal, internal 
strangulations, right-sided renal calculus, strangulation of a Meckel’s 
diverticulum, rupture of an extra-uterine pregnancy. In the female 
inflammation of the Fallopian tubes must be considered. 
In the vast majority of cases pain and tenderness in the right iliac fossa, with 
local physical signs, are sufficiently diagnostic of appendicitis to justify serious 
consideration of operative interference. On the other hand, the signs of appen- 
dicitis may be markedly atypical and lead to error. The pain and tenderness may 
be remote from the usual seat of the appendix; no tumor may be perceptible; 
the pulse and temperature may be normal; the bowels free; in fact, the varia- 
tions in the symptoms not infrequently seen in peritonitis may appear also in 
appendicitis. 
Treatment.—The treatment of acute appendicitis depends first 
upon the period at which the disease is recognized. Without doubt the 
best treatment, could it be applied in the first hours of the disease, 
would be immediate exploration and removal of the appendix. Inas- 
much as few cases come into the surgeon’s hands so early in the dis- 
ease, however, the question of operation becomes one much more difficult 
of solution. The rule demanding that every case of appendicitis be ope- 
rated upon as soon as the diagnosis is made is not approved by the DISEASES OF THE VERMIFORM APPENDIX. 
379 
majority of those most experienced in the treatment of the disease. It 
is extremely desirable to remove the appendix in the interval of health— 
to ease the patient, if possible, through an acute attack with an intercur- 
rent operation in view. Certain cases justify medical treatment for this 
end. Whatever may have been the indications in the early hours of the 
disease, its probable course can usually be determined with some certainty 
at the end of the second, third, or fourth day, the period at which the 
case is usually seen by the surgeon for the first time. The infection at 
this time is either successfully localized or it has become general. When 
successfully localized, the case may be watched if the constitutional 
symptoms are not severe or if they are improving. Yet even in the 
face of an undoubted amelioration of the constitutional signs delay is 
not justifiable when the local symptoms are conspicuous. In many 
cases the temperature and the pulse fall, even in the presence of a 
marked tumor. Such localized collections of pus must be evacuated 
immediately. When the local signs are mild, or when, with the con- 
stitutional ones, they are subsiding, delay is desirable. In all cases the 
most careful watch should be kept of both. When both local and con- 
stitutional symptoms are severe, even if there is no evidence of a gen- 
eral peritoneal infection, exploration is always demanded. 
Certain specific symptoms, however, in themselves demand exploration; 
such, for instance, as continued and intense pain, hoard-like rigidity of 
the muscles of the right side of the abdomen, constant vomiting, and high 
pulse, with or without increased temperature. On the other hand, a high 
temperature alone is of slight significance as an indication for operation; 
a high pulse alone is a much more reliable guide. In cases of doubt it is 
safer to operate than to delay. Localized abscesses should be opened as 
soon as they are recognized. 
The chief objection to operating on the third and fourth day in 
cases that are doing fairly well—cases in which, presumably, an ad- 
hesive barrier against the extension of infection has been successfully 
made—lies in the danger of converting a local into a general inflamma- 
tion. That this danger is great numerous observations seem to prove. 
Many a patient that was doing not perfectly, but fairly well, has had 
the scale turned against him by injudicious interference. 
Operation.—The guide to the incision should be the tumor ; if none 
be present, the seat of greatest tenderness. In the absence of definite 
localizing signs the cut should be made over the usual seat of the 
appendix—namely, halfway between the umbilicus and the anterior 
superior spine of the ileum. The incision should be a long one, par- 
allel with the fibres of the obliquus externus and across the interims and 
transversalis, so that clear inspection and free manipulation may be pos- 
sible. In most cases oedema of the celhdar tissue between the abdominal 
muscles will show that the surgeon is on the right track. The peri- 
toneum is often so changed that it cannot be recognized. It must be 
incised with the greatest care, for many instances have occurred in which 
the knife has gone directly into the intestine. As soon as the peritoneum 
is opened, if there be any intra-abdominal lesion present, serum, either 
clear or turbid, will escape. Turbid serum generally, though not always, 
contains micro-organisms ; serum containing gas and faeces indicates a 
general fecal infection. If the peritonitis be limited, and if it must be 380 
SURGERY OF THE ABDOMEN. 
approached through the general cavity of the abdomen, gauze barriers 
against general infection should be carefully placed toward the median 
line on all sides of the tumor. In cases of abscess in’cised through strong 
adhesions the operator should be content with simple drainage when the 
appendix is not easily accessible. The appendix should be removed when- 
ever it is possible to do so without infecting the abdominal cavity. In 
those operations in which the peritoneal cavity is necessarily opened no 
further harm can follow removal of the appendix itself. Separation of 
the appendix can generally be accomplished easily with the finger. A 
little experience will enable the surgeon, by the sense of touch, to detect 
the appendix without question, and to determine the extent and strength 
of the adhesions. In most cases the appendix can be easily delivered. 
It should be tied through its base and through its mesentery with cat- 
gut : silk becomes infected and causes a sinus which persists until it is 
cast off*. After removal of the appendix the parts should be carefully 
dried with sterile gauze. If the surrounding intestines are extensively 
infected, irrigation with salt solution or with warm water should be 
employed. In local infections general irrigation is not advisable, 
because it may spread the micro-organisms into remote regions of the 
abdomen. Great attention should be given to cleansing and drying the 
pelvis. 
If the pus-cavity be large, tubes and gauze should be used; if small and dry, 
gauze alone. In many instances peroxide of hydrogen seems an excellent solution 
to use for local irrigation. The abdominal wound may be left entirely open or the 
ends may be closed by one or two stitches. 
The Use of Salines.—In the beginning of an attack of appendicitis 
salines or other cathartics should not be used, for fear of causing by 
an increase of peristalsis and liquefaction of intestinal contents extrava- 
sation through a possible perforation. Many cases doubtless are bene- 
fited by free exhibition of cathartics, but, on the other hand, cases are not 
infrequently hurried into a general infection by this means. As soon as 
the appendix has been secured free catharsis is certainly desirable. This 
may be accomplished by Epsom salts in drachm doses of the saturated 
solution or by minute, oft-repeated doses of calomel. Both of these 
cathartics may be used in connection with enemata of glycerin and 
salts introduced high in the rectum. (See Peritonitis.) 
Chronic Appendicitis; Relapsing- Appendicitis; Catarrhal 
Appendicitis.—Whatever may be the pathology of the various lesions 
included under the term chronic appendicitis, the symptoms are usually 
definite enough to permit a determination of the existing cause. The 
symptoms are referable directly to the appendix and indirectly to the 
intestinal tract. 
The chief symptom is pain in the region of the appendix—pain either 
paroxysmal and intermittent or dull and constant. Local tenderness 
almost invariably accompanies the pain. In some instances the affection 
is persistent, in others intermittent; in some the attack is well defined, 
in others obscure. Digestive disturbances are usually present, and fre- 
quently constitute the chief symptoms. The appendicular symptoms are 
often attributed to indiscretion in diet. The bowels mayor may not be 
affected. In some cases there is diarrhoea ; in others, constipation. The 
pain is sometimes violent and paroxysmal; sometimes slight and con- DISEASES OF THE VERMIFORM APPENDIX. 
381 
tinuous. In some cases there is fever; in others, none. In a word, there 
is a grumbling appendix, which causes sometimes local, sometimes remote, 
signs, sometimes both. As a rule, chronic appendicitis manifests itself 
by local signs more or less severe, with chronic digestive disarrangement 
and general invalidism. 
Treatment of Chronic Appendicitis.—The treatment of this 
disease should be invariably surgical—first, because of the disability it 
causes, and secondly, because of the danger of an acute, fulminating 
exacerbation. Moreover, the patient can never safely go beyond the 
reach of a surgeon. The great safety of aseptic methods removes the 
chief objection to the performance of appendectomy. A minor objec- 
tion, the liability to hernia, is practically removed by the present 
methods of operating. 
Indications for Removing- the Vermiform Appendix in the 
Period of Health.—This question should be seriously considered in at 
least three classes of cases : 
(1) After recovery without operation from one severe attack ; 
(2) After numerous mild attacks ; 
(3) When local symptoms exist after drainage of appendicular 
abscesses without removal of the appendix. In this class may be con- 
sidered the removal of the appendix during the operation for hernia in 
the scar. 
(1) After full recovery from one severe attack of appendicitis removal of the 
appendix should be seriously considered, because a second attack may occur and 
be rapidly fatal. That such a sequel may, and often does, follow is shown by 
pathology and by experience. Moreover, the peritoneum about the appendix, 
altered by the first inflammation, does not resist a spreading infection as successfully 
as in the first instance. 
(2) The appendix should be removed in the period of health in those patients 
who suffer from many mild attacks, because of the pain, discomfort, and appre- 
hension which it causes. Though the pathology in these recurring mild attacks 
may be entirely different from that of gangrene and perforation, the chances 
favor local infectious processes in appendices which are the seat of chronic 
changes. 
(3) The appendix should be removed when local symptoms recur after the 
drainage of appendicular abscesses without removal of the appendix, because the 
abundant experience of the past few years proves that in a considerable percentage 
of cases serious and even fatal attacks may take place after such operation. It is 
clear that the appendix should not be removed in cases of localized abscess unless 
it can be removed without opening and infecting the peritoneal cavity; hence many 
operations are performed in which the appendix is not excised. In cases treated 
by drainage hernia in the scar is common. In such cases the advantage of closing 
the hernia, and at the same'time of removing the appendix, is so great as to justify 
recourse to operative measures when this condition exists. 
In all of the foregoing conditions removal of the appendix seems a most rational 
procedure, in view of the dangers of recurrence, however small they may be. The 
patient is relieved from discomfort, disability, and pain ; he need not so regulate 
his life as to be within easy reach of a surgeon; after the operation there is little 
if any danger of hernia, and practically no mortality. Appendectomy in the inter- 
val of health is one of the most successful and gratifying operations in all abdominal 
surgery. Though an occasional mistake is made in that a healthy appendix is 
excised, its safe removal cannot but prove a source of satisfaction to the patient. 
Operation for Removal of the Appendix in the Period of Health. 
—The method of McBurney is by far the best. The incision, an inch 
or an inch and a half in length, should generally be made over the seat 
of tenderness, sometimes not more than halfway between the umbili- 382 
SURGERY OF THE ABDOMEN. 
cus and the anterior superior spine of the ilium. The fibres of the external 
oblique or its aponeuroses are then separated longitudinally and retracted. 
The fibres of the internal oblique and transversalis are next separated 
in a similar manner. The retractors are then so shifted as to separate 
these muscular bundles. The peritoneum is next opened and retracted. 
By digital examination the exact situation of the appendix is determined. 
The caecum is carefully pulled out of the wound between the thumb 
and fore finger. If it slips, pieces of gauze may be used to aid in 
delivery. As the caecum is pulled out it should be passed between the 
fingers along the longitudinal striae toward the appendix. Non-adherent 
appendices will usually be delivered in this manner without exposing 
much of the caecum. If the base of the appendix, even in adherent 
cases, can thus be brought out of the wound, the rest of the organ can 
usually be separated with the finger. If the adhesions are so strong as 
not to be easily separable in this manner, the incision should be enlarged 
enough for free inspection and manipulation. Violent efforts at sepa- 
rating adhesions should not be made through the small opening already 
described. In many cases the vermiform appendix may be delivered 
and removed through an incision not wider than the thumb-nail. Not 
that it is necessary always to make so short an incision ; it is probably 
better, as a rule, to make a larger one, for it is often difficult to return 
the caecum through the opening after the operation has been completed. 
The meso-appendix must be tied with great care. The appendix itself 
should be tied close to the caecum, preferably with silk, and separated 
by means of the actual cautery. If this is not at hand, the stump may 
Fig. 174. 
Appendectomy: the meso-appendix has been tied, the appendix removed, and the stitches are 
in position to bury the stump. 
be treated with strong carbolie acid or with a strong solution of corro- 
sive sublimate. When practicable, the stump of the appendix should 
be buried by infolding it in the efecal wall (Fig. 174). Some surgeons 
make, near the base of the appendix, a cuff of peritoneum, which is SURGERY OF THE PERITONEUM. 
383 
inverted and sewed over the stump. Infolding or covering the stump in 
the manner just described is probably unnecessary, for cases in which 
such a technique is impossible seem to progress equally well. In remov- 
ing the appendix from its mesentery special care must be taken that the 
ligatures are securely tied. They should be of fine silk. The dangers 
being hemorrhage and sepsis, great care must be taken to avoid both. 
The abdominal wound is closed by two or three interrupted sutures. In 
the short incision above described one deep suture is sufficient. The 
mortality, in the hands of experienced operators, is probably less than 2 
per cent. 
SURGERY OF THE PERITONEUM. 
In the consideration of surgical diseases of the abdominal viscera the 
peritoneum is of the utmost importance. Two of its attributes require 
brief attention. The first is its power of forming adhesions ; the second, 
its power of rapid absorption. Upon the former depend the efficient 
walling-off of septic foci and the success of many abdominal operations ; 
upon the latter, the absorption of hemorrhagic, serous, and septic exu- 
dations. 
Surgery of the Peritoneum. 
The formation of adhesions requires an irritation, mechanical, chem- 
ical, or septic, of the opposing peritoneal surfaces. The production of 
adhesions does not therefore necessarily require the presence of a micro- 
organism, for aseptic surfaces scratched with a needle and approximated 
adhere almost immediately. 
The importance of adhesive barriers in the prevention of extravasations is 
obvious, for example, in the lesions of gastric, duodenal, and intestinal ulcer and 
in perforations of the vermiform appendix. 
The vast powers of absorption possessed by the peritoneum exert a powerful 
influence in widely different directions. It absorbs benign exudations into the gen- 
eral circulation with extreme rapidity; it absorbs with equal rapidity the ptomaines 
of bacterial growth. This attribute explains the early and profound systemic 
depression of general peritonitis, and upon it rests the theory of the saline treat- 
ment of peritoneal infection—a treatment by which intestinal drainage is supposed 
to remove the toxic products of germ-growth as fast as the peritoneum absorbs 
them. 
The peritoneum with its great extent of surface and its enormous powers of 
exudation presents a fertile medium for the growth of germ colonies—colonies 
which reproduce themselves with deplorable rapidity, luxuriance, and virulence. 
Peritonitis, by far the most important affection of the abdominal 
cavity, is a disease which is wholly and absolutely dependent upon micro- 
organisms. Aseptic peritonitis does not exist under the modern definition 
of the term, though it may be impossible by any known method of culture- 
staining always to demonstrate the presence of the causative germ. The 
extent and virulence of peritonitis are undoubtedly influenced largely by 
the growth, the reproduction, and the absorption of the micro-organisms 
present. Though it is as yet impossible to classify the varying forms of 
peritoneal inflammation at present described under the broad term 'peri- 
tonitis, it is not without strong probability that a bacteriological classi- 
fication will eventually be adopted. 384 
SURGERY OF THE ABDOMEN. 
Tlie causes of peritonitis through which micro-organisms are introduced into 
the peritoneal cavity are—(1) Extravasations from the alimentary canal—the stomach, 
the intestines, and the vermiform appendix; from other septic hollow viscera—the 
gall- and urinary bladders, the pelvis of the kidney; from the genital organs of 
the female through the uterus and tubes; from the rupture of abscesses. (2) Intra- 
abdominal necroses, which, though less common than the first group, include many 
of the gravest possible abdominal emergencies: (a) internal strangulation; (b) 
intussusception; (c) volvulus; (d) embolism and thrombosis of the mesenteric ves- 
sels; (e) gangrenous pancreatitis, gangrenous splenitis; (/) fat-necrosis; (g) ova- 
rian and other tumors with twisted pedicle; (h) movable kidney and wandering 
spleen with twisted pedicle. (3) Contamination by septic materials, missiles, instru- 
ments, and fingers. (4) Infections conveyed to the peritoneum, through the circula- 
tion, from remote foci: (a) rheumatic, gonorrhoeal, and syphilitic peritonitis, in 
which the direct communication between the original disease and the infection 
has not as yet been clearly demonstrated, and in which septic peritonitis is favored 
by the low state of the system in these diseases. (5) The so-called chemical peri- 
tonitis, dependent upon the irritation of chemical solutions, should not be included 
under the term peritonitis unless it is associated with the presence of a micro- 
organism. 
The pathological condition may be described as an intense local inflam- 
mation, with constitutional absorption. 
In the first hours of the infection, during which the lesion is now so often 
demonstrated, the gross appearances of the peritoneum are little if at all changed. 
Dilatation of the blood-vessels produces general deepening of the color. A clear 
serous exudation results from the initial congestion. The enormous reproduction 
of germ colonies in the peritoneum itself produces here and there broad flakes of 
lymph intimately connected with the intestinal wall. The serous exudate, hold- 
ing suspended germs in vast numbers, becomes turbid. When the infection is at its 
height the peritoneum is everywhere intensely congested, especially over the small 
intestine; the color is deepened, the muscular contractions enfeebled, and the 
intestine finally paralyzed and distended. Easily-separated adhesions form 
between contiguous surfaces. Upon the distended coils, here and there, dark 
blotches appear; the intestinal wall is thickened; its peritoneum opaque. As 
the infection progresses the number and extent of the lymph-flakes increase, 
becoming occasionally detached and floating in the dependent serum. The disten- 
tion of the intestinal wall from gas-formation becomes excessive. The serum from 
being turbid may become opaque, green, greenish yellow, yellow, hemorrhagic; from 
being thin and watery it may become thick, creamy, or grumous. In extrava- 
sations from the alimentary canal the exudate is always foul-smelling and gen- 
erally contains gas. 
If the patient survives the advanced stages of this infection, the congestion and 
thickening of the intestinal wall increase to a marked degree. The exudation 
becomes distinctly purulent and bathes everywhere the abdominal viscera. Beyond 
this stage practically all infections are from a comparatively mild germ. The 
gross appearances now become those of abscess. General peritoneal abscess is 
rarely demonstrated during life, though it is not infrequently found at autopsies. 
The whole peritoneal cavity may consist of a single collection of pus, or limited 
foci, surrounded by adhesions, may be scattered throughout the whole peritoneal 
space. 
The appearances of local peritonitis, which every surgeon has abundant oppor- 
tunities of observing, do not differ materially from those of the general form except 
in extent. The congestion and thickening of the peritoneal wall is excessive; the 
adhesions are strong; the lymph-deposit general throughout the localized cavity. 
The results of infection are prominent in the omentum, which has a special pro- 
clivity for wrapping itself about contaminated areas. The omentum becomes exces- 
sively thickened, congested, and discolored; the portion in contact with the exu- 
dation is covered with a yellowish-green lymph. In places it seems gangrenous. 
A true gangrenous process, however, rarely results from bacterial invasion unless 
there is also strangulation, thrombosis, and embolism. The lymph-flakes can 
always be easily removed, leaving an area of intense congestion and induration. 
The tumor or cake of a localized peritonitis, especially exemplified in inflamma- SURGERY OF THE PERITONEUM. 
385 
tion about the vermiform appendix, is due largely to the great thickening of the 
adherent omentum. 
The bacteriology of peritonitis is of the utmost interest and importance. No case 
should be recorded as one of peritonitis in which the diagnosis does not rest upon 
an expert bacteriological examination. The bacterial forms which exert the most 
frequent and powerful influences, according to our present knowledge, are the bacillus 
coli communis and the streptococcus. Less rapid and virulent, though unfortunately 
fatal, micro-organisms are the various staphylococci, the pneumococcus, etc. The 
influence of the gonococcus is as yet undetermined. In the peritonitis of intestinal 
extravasations the bacillus coli communis, usually found in pure cultures, is doubt- 
less associated with many other forms of intestinal bacteria, which are masked by 
the luxuriance and rapidity of growth characteristic of the colon bacillus. In 
fecal extravasations gas-forming bacteria are almost invariably present. ( Vide 
Chapter III. Yol. I.) 
Differentiation by gross appearances between the various forms of bacterial 
infection is impossible, for they are not characteristic. Indeed, cases have occurred 
presenting the typical gross signs of peritonitis in which cultures have remained 
sterile. 
The colon bacillus has been observed chiefly in appendicitis. Its malign 
influence in peritonitis may have been overrated, for pure cultures have been 
injected into the peritoneum of guinea-pigs without bad results. The fulminating 
variety of peritonitis, if not dependent upon the colon bacillus, must be caused by 
a germ of extreme virulence like the streptococcus, which is masked by the rapid 
growth of the former. In long-standing abscesses of appendicular origin a mixed 
infection is often found containing a variety of pathogenic micro-organisms. 
Streptococcus infections pursue a most virulent course. They usually proceed 
from the uterus and tubes. Infections from the hands or from the instruments are 
often of this variety. The pathogenic staphylococci are introduced through various 
channels. Their course is less fulminating, though usually fatal. The cases which 
are cured by drainage are probably of this variety. The influence of the pneu- 
mococcus is little understood; that of the gonococcus, not at all. All cases of 
gonorrhoeal peritonitis, so far as known, have been mixed infections. 
Doubtless other germs, as yet undescribed, have an important bearing upon 
the course and prognosis of peritonitis. Yet it has been frequently observed 
(Massachusetts General Hospital) that in cases presenting the history and gross 
signs of general peritoneal infection recovery follows, as a rule, if the cultures from, 
the serous exudate are sterile on ordinary media (agar and blood-serum). (See 
Appendicitis.) 
Symptoms.—From what has been said above, it is obvious that the 
symptoms of general peritoneal infections must vary between extreme 
limits. Yet certain cardinal symptoms are almost invariably present. 
They are pain, tenderness, vomiting, shock; rigidity of the abdomen, 
followed by distention; constipation, fever, systemic depression, collapse. 
Pain is usually the earliest symptom of peritonitis, though it may be 
absent; it is at first local, later general. In local peritonitis, as exempli- 
fied in appendicitis, it is often first general; later, local. It may be sharp 
(extravasation), paroxysmal (colic), or dull. In the later stages the 
pain may subside or disappear. Tenderness is almost always present. 
It varies in degree and in extent ; is often local, becoming general, or 
general, becoming local; it maybe exquisite or it maybe noticeable 
only on deep pressure. It is a better guide to the causative lesion than 
pain, being more definitely referred. Rigidity from reflex spasm of the 
abdominal muscles, a symptom of the greatest importance, is always 
present in rapid extravasations. Rigidity points more definitely to a 
serious internal lesion than any other one symptom. Nothing less 
grave than a lesion threatening life itself can account for this symptom 
when it is associated with pain, tenderness, and shock. 
Distention follows rigidity as soon as the infection, through intestinal 386 
SURGERY OF THE ABDOMEN. 
paresis, causes stasis of the intestinal stream. The intestines are often 
distended to an excessive degree. Obstipation and cessation of internal 
sounds are coincident with distention from the same causes. Vomiting is 
an early symptom in peritonitis; at times the very first. The vomitus 
consists in the beginning of the contents of the stomach ; later it becomes 
green, then dark or fecal. In some instances it is the only conspicuous 
symptom throughout the disease, the patient dying of exhaustion, without 
pain, tenderness, fever, or distention. The signs of constitutional infec- 
tion are also perplexingly various. At times the temperature rises rapidly 
to 104° or 105° or more; stays there or rapidly falls; at times it is prac- 
tically normal, at times moderately elevated. 
The pulse is more constantly affected than the temperature, rising 
rapidly or slowly, but continuously. In the rarest instances it may 
remain normal or but slightly elevated until the infection is fully 
developed and hopeless. The pulse, better than the temperature, indi- 
cates the patient’s true condition. A temperature falling to normal or 
subnormal, with a rising pulse, is a combination of the gravest import. 
The facies of peritonitis is characteristic. The eyes are hollow and the 
cheeks dark red. 
The systemic depression of peritonitis is always grave. In some 
instances the initial shock is profound. With the progress of the 
disease depression becomes extreme and the patient dies in collapse. 
The usual symptoms are present in the shock and collapse of peritonitis. 
The enfeebled state of the circulation shows itself not only in a rapid 
and weak pulse, but in cold extremities and in lividity of the skin of the 
abdominal wall; the latter symptom, however, may be present when the 
patient’s general condition is fairly good. Combined with rigidity, 
abdominal lividity, as shown by the slow disappearance of finger-marks, 
is a grave symptom. 
In the early stages, when operative interference is advisable and not without 
hope, the symptoms may be grouped as follows: 
(1) Pain general, becoming local; or local, becoming general, according to 
cause; 
(2) Tenderness, general, becoming local; or local, becoming general; 
(3) Rigidity of the abdominal muscles; 
{4) Vomiting, green; 
(5) Rise of pulse and temperature; 
(6) Shock, varying in depth ; 
(7) Diminished peristalsis. 
In fully-developed peritonitis, in which the wisdom of interference is question- 
able, the symptoms are— 
(1) Pain lessened or absent; 
(2) Tenderness general; 
(3) Distention excessive, replacing rigidity ; 
(4) Vomiting excessive, dark or fecal; 
(5) Obstipation; peristaltic movements not heard ; 
(6) Rapid and feeble pulse; 
(7) High or low temperature ; 
(8) Lividity of abdominal skin ; cold extremities ; 
(9) Peritoneal facies; 
(10) Mind clear. 
In hopeless cases the above symptoms are increased with collapse; the patient 
is moribund. SURGERY OF THE PERITONEUM. 
387 
The diagnosis of general peritonitis is usually easy. The diseases 
most likely to be confounded with it are peritoneal hemorrhage and acute 
intestinal obstruction. It is not always possible to make a diagnosis 
without exploration. Abdominal hemorrhage, particularly of the extra- 
uterine variety, begins with sharp pain, is accompanied by shock and 
systemic depression, and is not infrequently attended by marked con- 
stitutional symptoms. The symptoms of ruptured ectopic gestation are 
usually accompanied by one or more signs of pregnancy. When the 
signs of hemorrhage are present no confusion is likely to ensue; errors 
may nevertheless arise, for many cases of hemorrhage simulate general 
peritonitis, without being extensive enough to cause faintness. The 
diagnosis between general infection and acute obstructions is also at 
times difficult, if not impossible. (See Acute Intestinal Obstructions.) 
Acute abdominal symptoms demanding exploration are always con- 
spicuous, whatever the cause may be that produces them. In cases of 
doubt it is the part of wisdom to explore. 
The treatment of peritonitis may be medical—i. e. opium to prevent 
peristalsis or cathartics to increase it; or surgical—irrigation and drain- 
age. In the vast majority of cases, however, all methods fail. 
Medical treatment should not be dismissed with a word, for it is better adapted 
to many cases than surgical. Cathartics, salines or others, are indicated at the 
beginning of the invasion, when the disease is feared rather than recognized, and 
before vomiting is frequent or excessive. On theoretical grounds intestinal drain- 
age by means of excessive liquid stools may remove so effectually the peritoneal 
exudate as to absorb the infection. If the truth were known, however, it would 
doubtless appear that in many cases no real infection was present or even impend- 
ing. The absolute futility of cathartics in advanced cases of demonstrated peri- 
tonitis lends confirmation to this statement. Nevertheless, free watery evacuations 
undoubtedly encourage the elimination of ptomaines. Saline cathartics should be 
used only in the early stages when vomiting is not excessive. Calomel in small, 
divided doses, one-fifth of a grain every hour, will at times produce satisfactory 
discharges. 
Cathartics should never be used when intestinal perforations are suspected, for 
fear of increasing the extravasation. Opium should not he used unless absolutely 
necessary. It is indispensable in those cases in which the pain cannot be borne, 
and in which the harm it may do is more than offset by the relief it affords the 
patient. 
The surgical treatment of peritonitis consists (1) in the removal 
of the cause, and (2) in the removal of its effects. (The treatment of the 
various causes is described elsewhere.) The second indication requires 
incision, irrigation, or cleansing and drainage. The incision must be in 
the median line. Its extent and situation will depend upon the cause 
of the infection. 
The median incision should be made below the umbilicus. As soon 
as the peritoneum is nicked serum will escape. The appearance of the 
serum may indicate in a general way the nature of the infection. If 
clear, turbid, or purulent, without odor, the infection does not depend 
upon the alimentary canal; if foul-smelling and fecal, it comes from the 
intestinal tract, or, rarely, the tubes ; if urinous, from the genito-urinary 
tract; if hemorrhagic, without sepsis, there is mistaken diagnosis. The 
escape of fluid of one kind or another justifies the exploration and indi- 
cates its further prosecution. The incision should be enlarged and the 
fluid in the dependent portions of the abdominal cavity removed as 388 
SURGERY OF THE ABDOMEN. 
thoroughly as possible by means of gauze or sponges. The exploration 
should then proceed according to the circumstances of the case. (See 
Special Causes of Peritonitis.) 
During the exploration, folds of gauze placed deep in the pelvis will suck out 
large quantities of fluid and facilitate the final cleansing. The local lesion having 
been repaired or removed, the whole abdominal cavity should be inundated with 
sterile solutions—preferably the normal salt solution—which may be introduced by 
means of a funnel and rubber tubing through a blunt-pointed nozzle either of 
glass or of metal. When the irrigation is deemed sufficient, the fluid should be 
removed by means of dry sterile gauze or of sterile sponges applied deep in the 
pelvis and the flanks. Drainage is best accomplished by means of gauze wicks, 
with or without drainage-tubes. The tubes and the wicks should lead from the 
abdominal incision into each flank and into the pelvis. Drainage may be facili- 
tated by incision through the flanks and out of the back. The value of antiseptic 
solutions for irrigation is questionable, though many use corrosive sublimate, 
1: 20,000, peroxide of hydrogen or boracic acid. 
The manipulations described above are seriously interfered with when 
distention is excessive or even moderate; the intestines escape from the 
wound the moment pressure upon them is relaxed. Under excessive 
intra-abdominal pressure it is practically impossible to bring the irrigat- 
ing fluid thoroughly in contact with the diseased coils unless evisceration 
is complete—a procedure which adds greatly to the shock and which is 
not infrequently the immediate cause of death. To empty the distended 
coils and to relieve distention aspiration and free incision have been prac- 
tised. The latter is of doubtful utility, because a single incision will 
empty but a single coil. The multiple incisions necessary—all requir- 
ing suture—accomplish too little in the relief of distention to make them 
of'much practical value. A single coil when opened may be fastened to 
the external wound for a temporary anus. As a rule, no considerable 
nor lasting effect follows either enterotomy or artificial anus. 
Acute general peritonitis, when fully developed, presents almost 
insuperable obstacles to effective drainage. The colonies of micro- 
organisms make their way into the remotest recesses of the abdominal 
cavity, which, shut off by immediate adhesions, cannot be efficiently 
drained. General peritoneal infections, for this reason alone, must be 
fatal in the vast majority of cases under any method of treatment at 
present known. 
The after-treatment requires stimulation and rectal feeding. If it be possible 
by the use of salines to start up peristalsis without further increasing the systemic 
depression, salines, though often nauseating, should be used. Peristalsis can some- 
times be stimulated by the use of high rectal enemata containing powdered aloes 
gr. xxx, Epsom salts 5_j, glycerin 3ij, water Oj. 
The prognosis in general peritonitis after operation depends, first, upon the 
nature of the micro-organisms, and, secondly, upon the stage of the infection. In 
estimating the mortality we must repeat our conviction that no cases are worthy of 
record in which an expert bacteriological examination has not been made. 
The writer’s experience in general peritoneal infections of an advanced stage 
is so discouraging that he welcomes statistics that go to show that even 5 or 10 per 
cent, recover. Some of the more recently reported results after operation vary so 
extremely that the conviction is irresistible that different writers, in giving their 
successes or their failures, are not describing the same conditions. When cases in 
one community are always fatal, no matter how or by whom treated, while those 
in another show a large number of recoveries, presumption is raised that reporters 
are not discussing the same conditions. No disease affecting the abdominal cavity 
offers a richer field for investigation than peritonitis. TUBERCULAR PERITONITIS. 
389 
Tubercular Peritonitis. 
Tubercle bacilli may reach the peritoneum from the genito-urinary 
or intestinal tract, from the mesenteric nodes or by way of the circula- 
tion, from any tubercular focus, or in the course of a general acute mili- 
ary tuberculosis. In males the usual source of infection is the intestinal 
tract—more rarely the genito-urinary; in females, the reproductive 
organs. In children the mesenteric nodes are primarily affected by 
direct inoculation through the intestinal mucous membrane. 
The disease manifests itself in three forms : (a) The ascitic form— 
tubercular ascites ; (6) the dry fibrino-plastic form—adhesive tuber- 
cular peritonitis; and (c) the ulcerative or suppurative form. 
(a) In tubercular ascites the peritoneum is studded with minute tubercles 
throughout its whole extent or in a definitely localized region. This form of tuber- 
cular peritonitis is always accompanied by a serous exudation. If the process is 
general and unconfined by intestinal adhesions to one or more localities, the exu- 
dation will be encysted and moderate. Several collections of encysted fluid may 
be present. 
(b) In the dry adhesive variety there is no serum; fibrin glues the intestines 
together in a closely adherent mass. 
(c) The caseous ulcerative and suppurative forms of the disease are but steps 
in the retrograde necrotic processes seen in all forms of tubercular disease. In this 
form ulceration and perforation of the bowel and the formation of internal fistulae 
frequently take place. The intestines may be extensively attached to each other and 
to the abdominal Avail by adhesions which enclose numerous collections of pus and 
caseous material. 
Symptoms.—The symptoms of tubercular peritonitis are usually 
vague. There is generally malaise and emaciation, variable hectic 
fever, gastro-intestinal disorders, diarrhoea, and occasionally pain and 
tenderness in the abdomen. 
In the ascitic form abdominal distention develops rapidly and calls 
attention to the disease. In the adhesive variety the symptoms are 
obscure. From the matting together of the omentum and intestinal 
coils the abdominal condition may simulate on palpation any form of 
intra-abdominal tumor. In the encysted form tubercular peritonitis 
may be mistaken for hydronephrosis, dilated gall-bladder, cysts of the 
omentum, mesentery, or spleen. The adhesive variety may closely simu- 
late malignant disease. 
In the idcerative form the constitutional symptoms are more 
extreme, the fever more constant and severe, and the abdominal tender- 
ness more marked. Cases of emaciation and malaise attended by vague 
gastro-intestinal symptoms and variable fever should be investigated 
closely, for these symptoms always suggest the presence of tubercular 
peritonitis. Cases of the general ascitic form have not infrequently 
been mistaken for ovarian cysts. 
Treatment may be palliative or operative. Operative measures 
are demanded in all cases in which the presence of advanced tubercular 
disease in other organs does not offer contraindication. Palliative meas- 
ures do not differ from the medical treatment of all tubercular processes. 
Ascitic distention may be relieved by occasional aspiration. 
Surgical treatment consists in incision and free evacuation of the 
fluid, with or without prolonged drainage. The fluid should be removed 
as thoroughly as possible by median incision below the umbilicus. 390 
SURGERY OF THE ABDOMEN. 
Additional drainage may be established by incision through the flanks. 
A single incision, with thorough evacuation of the serous exudate and 
immediate closure, is followed by quite as good results as prolonged 
drainage by means of gauze and tubes. Moreover, prolonged drainage 
by those means may be followed by a persistent sinus or a fecal fistula. 
Care must be taken not to open adherent bowel in making the 
incision through the abdominal wall. 
The ascitic form is the one most favorable for operation, the ulcer- 
ative form the least. Statistics show 35 per cent, of cures after opera- 
tion in the ascitic form of the disease. Operation is most successful in 
children and young adults. 
The clinical resemblance between simple fibrous peritonitis (peritonitis nodosa), 
cancerous peritonitis, and tubercular ascites is so close that a positive diagnosis of 
tubercular peritonitis with ascites requires an expert microscopic examination of 
one or more tubercles or nodes. 
Perforations of Typhoid Ulcers. 
Surgical treatment in typhoid ulcers is applicable to between 6 and 
7 per cent, of the cases which result in perforation. From the nature 
Fig. 175. 
Extensive perforation from ulceration of Peyer’s patch in typhoid fever in the third week 
(Warren Museum). 
of the constitutional disease, from the extreme rapidity with which 
the peritoneum becomes infected by intestinal extravasation, from the 
dangers incident to the operation itself, the chances of saving any con- 
siderable number of cases are extremely small; yet in 23 reported ope- 
rations there were 7 recoveries—a record which is better than could 
reasonably have been expected. SURGERY OF THE OMENTUM. 
391 
The pathological process by which perforations take place differs but little 
from the slower course of gastric, duodenal, or intestinal ulcers. As the ulceration 
approaches the serous coat the peritoneum becomes inflamed and adherent to 
continuous coils and viscera. In some instances these barriers result in the forma- 
tion of intestinal fistulse; in others they are insufficient to prevent a general 
extravasation. Slight extravasations may cause only localized abscesses; extensive 
ones, fulminating infections. 
The surgery in general of typhoidal ulcers is that of general peri- 
toneal infection or of localized abscesses. 
The symptoms of perforation of typhoidal ulcers are those of intes- 
tinal perforations from other causes—an aggravated general peritonitis 
with the symptoms of the already existing constitutional disease. When 
in the course of a typhoid fever, mild or severe, the patient is seized 
with intense pain, followed by tenderness, abdominal rigidity, distention, 
and shock, the perforation of a typhoidal ulcer is almost beyond ques- 
tion. Most cases go on to a fatal termination in the course of a few 
hours. 
Unless the collapse is extreme, the treatment demanded is imme- 
diate exploration. The incision should be made in the median line, and 
the exact seat of the lesion determined. If but one perforation exists, 
the bowel may be infolded and sutured, as in the operative treatment of 
stomach ulcers. If the disease be too extensive to permit this method, 
the coil may be resected or it may be fastened temporarily into the 
wound. In case these methods are impracticable, gauze may be packed 
about the seat of perforation and brought out of the abdominal wound. 
The coexistent peritonitis should be treated like peritonitis from other 
causes. Abscesses require irrigation and drainage. 
(For Wounds and Ruptures of the Omentum see section on Abdom- 
inal Injuries.) 
Abscess of the omentum is a form of localized peritonitis. It may 
be due to septic infection after wounds or ruptures, or to extension from 
neighboring viscera, most frequently from the perforated appendix. 
The extraordinary capacity of the omentum for forming adhesive 
barriers against septic processes—extravasations and abscesses—not 
infrequently results in infection of the omentum itself with single or 
multiple abscesses. 
The diagnosis and treatment of omental abscesses are those of 
any local peritonitis with abscess-formation. 
New Growths of the Omentum.—Cysts of the omentum may be 
serous, hemorrhagic, hydatid, or lymphatic. 
Serous cysts of the omentum are generally of inflammatory origin. 
Blood-cysts have occasionally resulted from wounds or ruptures. Large 
multilocular lymph-cysts of the omentum are probably of congenital 
origin and due to dilatation of the lymph-channels. Hydatid cysts of 
the omentum are never primary. The so-called dermoid omental cysts 
have generally been found to be ovarian in origin. A cavernous angeioma 
of the omentum has recently been removed by Homans. 
Solid tumors of the omentum may be sarcomata, carcinomata, 
fibromata, or Vipomata. Carcinoma is never primary in the omentum. 
Surgery of the Omentum. 392 
SURGERY OF THE ABDOMEN. 
Infiltrations of the omentum secondary to cancer of other abdominal 
structures, and of the breast, are not uncommon. Sarcoma has been 
observed as a primary omental growth. In the fibro-cystic form it has 
been mistaken for a simple cyst. Fibroid and fatty tumors of the 
omentum are very rare. 
The omentum is involved in general peritoneal tuberculosis and in 
acute miliary tuberculosis. 
Diagnosis.—Omental tumors are seldom correctly diagnosticated 
before operations. Theoretically, a small, non-adherent omental tumor 
may be moved upward and laterally, but not downward, and will not move 
with respiration. It will appear superficial to inflated intestines or 
stomach. Large and extensively adherent tumors can only with diffi- 
culty be differentiated from other abdominal growths. Tumors con- 
fined to the omentum are not associated with functional disturbances, 
and are usually undiscovered until large enough to cause pressure- 
symptoms. 
Cysts of the omentum are often confused with ovarian cysts. Aspiration may 
be the only means of determining the cystic nature of an omental growth. 
Extensive adhesions and matting together of the omentum and intestines may 
simulate almost any form of intra-abdominal tumor. 
Treatment of omental tumors should invariably consist in ex- 
ploratory laparotomy with extirpation of the growth. Cysts which 
cannot be completely removed should be treated by incision and 
drainage. 
Diseases of the Mesentery. 
The mesentery is the seat of lesions, acute and chronic, which are at 
times of the greatest surgical importance. Prominent among them is 
tuberculosis of the lymph-nodes of the mesentery. This disease is asso- 
ciated with tubercular peritonitis, and is often a part of the disease. 
Occasionally, however, the lymph-nodes of the mesentery are alone 
infected; indeed, the infection may be limited to the mesentery of a 
single coil. A tuberculosis thus limited is of the deepest surgical inter- 
est, for free dissection may remove a focus of infection so close to the 
general lymph-reservoirs as to threaten life. Early and thorough 
removal of lymph-nodes thus affected may render tabes mesenterica a 
less formidable disease. 
The symptoms of mesenteric tuberculosis are those of peritoneal 
tuberculosis. A limited infection with enlargement of the lymph-nodes 
may cause a definite localized tumor, the nature of which can only be 
suspected. 
The treatment is that of tubercular peritonitis when the infection 
is extensive; when localized as a distinct tumor thorough extirpation 
is demanded. 
Mesenteric Embolism and Thrombosis.—Plugging of the mesen- 
teric vessels is probably more common than is usually supposed. Many 
cases of intestinal necrosis doubtless are dependent upon this lesion. 
The causes of embolism and thrombosis are similar to the causes of these 
lesions in vessels elsewhere. The results are most disastrous, for with 
the stasis of circulation necrotic changes in the intestine immediately PANCREAS. 
393 
appear. Death is sure to follow unless the affected coil is resected at 
■once, or at least isolated by gauze barriers and opened in the abdominal 
wound. 
The symptoms are at first indefinite. Pain is an early and promi- 
nent symptom; later appear the signs first of intestinal obstruction, 
and then of gangrene. Excision of the gangrenous coil before a gen- 
eral infection takes place offers a chance of permanent cure, as in 
Elliot’s case. 
Cysts of the mesentery are similar in origin, causes, symptoms, and 
treatment to cysts of the omentum (Fig. 176). 
Fig. 176. 
■Cyst of the mesentery, containing clear fluid. The hour-glass constriction passes through the 
layers of the mesentery (from a case occurring in the author’s practice). 
Pancreas. 
(Wounds and Injuries of the Pancreas are considered on page 341.) 
Pancreatitis may be either acute or chronic. The acute varieties 
are— 
Acute hemorrhagic pancreatitis; 
Acute suppurative pancreatitis; 
Acute gangrenous pancreatitis. 
Acute hemorrhagic pancreatitis is of surgical interest, because 
often mistaken for acute perforative peritonitis or acute intestinal 
obstruction. Operations worse than useless have been performed under 
such erroneous diagnoses. Its onset is sudden, its course rapid and 
severe, its end almost universally fatal. Those cases that survive the 
first day or two of the disease and result in pus-formation may possibly 
recover after drainage. 394 
SURGERY OF THE ABDOMEN. 
Acute suppurative pancreatitis or abscess of the pancreas is 
the result of invasion of any part of the gland by micro-organisms. 
Calculi, intestinal round-worms in the pancreatic duct, wounds, injuries, 
and cysts of the pancreas are predisposing causes. The septic pro- 
cess may extend to the pancreas from neighboring organs, especially 
from ulcers of the stomach or the duodenum. 
Suppuration may be manifested as a peripancreatitis, as a retroperitoneal abscess, 
or as multiple collections of pus disseminated throughout the pancreas. Multiple 
abscesses may degenerate into one large abscess-cavity, which may communicate 
with the duodenum or rupture into the general peritoneal cavity. The majority 
of cases of multiple abscess occur in adults under forty. 
Symptoms.—The symptoms in nearly every case point at first to the 
stomach or the liver. Fever is not constant; jaundice may exist; the 
urine may contain sugar. Ascites and oedema have been present in 
many cases. 
Diagnosis.—In most of the cases of suppurative pancreatitis the 
diagnosis has not been made before death. Emaciation, general malaise, 
and gastric disturbances, with variable symptoms of constitutional sep- 
sis, suggest the possibility of the disease. A tumor in the region of the 
pancreas confirms the diagnosis. To determine the situation of the 
tumor with reference to the stomach the latter may be inflated. The 
tumor may be in the epigastrium or in the right or left hypochondrium ; 
it may be observed in the first few days of the disease, or not for sev- 
eral weeks after the first symptom. 
The prognosis is grave. Death is caused by acute sepsis or by pro- 
gressive exhaustion. In most cases it occurs within a few days of the 
onset of the disease. Sudden death may be caused by rupture of abscess 
into the general peritoneal cavity. In rare cases rupture into the intes- 
tinal tract has resulted in spontaneous cure. 
Treatment.—Surgical interference in suppurative inflammations of 
the pancreas is indicated when the signs of pus are clear. Incision and 
drainage are demanded. Interference in the acute stage is contraindi- 
cated. The chief care in the operation should be to prevent contamina- 
tion of the general peritoneal cavity. Incision should be made in the 
median line, between the umbilicus and the ensiform cartilage, over the 
most prominent portion of the tumor. The stomach and transverse 
colon usually overlie the abscess and must be avoided. The layers of 
the omentum must be incised or torn to gain access to the pancreatic 
space. The general peritoneal cavity must be protected thoroughly by 
gauze. To establish the diagnosis the tumor may be explored with an 
aspirating needle before incision. If pus is found, the greater part of it 
should be drawn off through the needle, as in this way subsequent 
manipulations are facilitated and the danger of general peritoneal infec- 
tion is lessened. A free incision into the abscess should then be made 
and the cavity should be thoroughly irrigated. Drainage by means of 
gauze and drainage-tubes will be necessary, and must be continued as 
long as there is any discharge. Closure of the wound after too early a 
removal of the tubes will result in reaccumulation of the pus. Hemor- 
rhage from the abscess-cavity may be checked by gauze-packing. In 
some cases pus, starting from the pancreas and burrowing behind the PANCREAS. 
395 
peritoneum, will make its appearance as a fluctuating tumor in the flank. 
Such cases should be incised and drained from behind. 
Gangrene of the pancreas is the result of acute septic infection of 
the gland. The infection is usually of such virulence that surgical 
measures, to be of any use, must be applied at the earliest moment. 
Theoretically, there is no reason why a gangrenous pancreas should not 
be drained or the gangrenous portion removed. In rare cases spontan- 
eous cure has taken place by the sloughing of the necrosed gland into 
the intestine. 
Chronic pancreatitis or sclerosis of the pancreas is a form of 
chronic inflammation resulting in an increase of the connective tissue of 
the gland. The process may affect the whole organ. 
In the early stages of the disease the gland is large and vascular; in the later, 
small and contracted. This form of pancreatitis is of surgical importance because 
of the obstruction it may cause in the bile and pancreatic ducts. It is frequently 
associated with diabetes. The etiology is obscure, though pancreatic calculi or 
antecedent (suppurative) processes in adjacent organs may be possible causes. 
The indications for operative treatment are the symptoms of stricture 
of the common duct, with retention of bile or of pancreatic fluid. Per- 
sistent jaundice and emaciation, with little or no pain, suggest obstruc- 
tion of pancreatic origin. 
Surgical Treatment.—The only surgical treatment consists in chole- 
cyst-enterostomy, an operation for the relief of the biliary obstruction. 
Pancreatic Hemorrhag-e.—Extensive hemorrhages into the pancreas 
and peripancreatic tissues may be the cause of sudden death. This, how- 
ever, must not be confounded with the hemorrhagic form of pancreatitis. 
Slight hemorrhages into the body of the gland may cause hemorrhagic 
cysts of the pancreas. 
Pancreatic calculi are usually small, multiple, and white. In rare in- 
stances a single large stone is found. The calculi consist of phosphate or 
carbonate of lime. Pancreatic calculi have no surgical interest except that 
they may be the cause of pancreatic cysts and of chronic pancreatitis. 
Cysts of the pancreas are usually retention-cysts due to the impac- 
tion of calcnli in the pancreatic duct. 
Cysts of the pancreas may result from— 
(a) Obstruction of the pancreatic duct by calculi, with attendant 
changes in the parenchyma of the gland; 
(tj) Obstruction from cicatricial contractions of the duct; 
(c) Obstruction of the duct from displacement of the pancreas; 
(d) Obstruction of the duct from trauma. 
Cysts of the pancreas are globular in shape and may be as large as a 
man’s head. In cysts of rapid formation the wall is thin from disten- 
tion ; in those of slower growth it is thick ; it may be cartilaginous or 
ossified. An accessory pancreas may be the starting-point of the cyst. 
The symptoms of pancreatic cyst are chiefly local—indefinite pain 
or discomfort in the epigastrium, disturbances of intestinal digestion, 
varying in severity according to the amount of pancreatic fluid shut off 
from the duodenum. In some cases diabetes is present. The tumor 
itself is characteristic : it fills the space occupied by the pancreas and 
causes a symmetrical swelling in the epigastrium. It is often so tense 
as to seem solid. 396 
SURGERY OF THE ABDOMEN. 
The diagnosis must be made from the presence and physical attri- 
butes of the tumor. To determine the latter aspiration may be em- 
ployed. Cysts of the pancreas must be distinguished from cysts of the 
peritoneum and mesentery and from malignant disease of the pancreas. 
The operative treatment of pancreatic cysts should, in the vast majority 
of cases, be incision and drainage. A few cases have been reported in 
which complete extirpation of the cyst has been accomplished. The 
technical difficulties of extirpation practically exclude this operation, 
though enucleation of the cyst, if it can be effected without removing 
the entire gland, may be attempted. The dangers of enucleation are 
chiefly those of hemorrhage and shock. Drainage of pancreatic cysts 
should be made through a median incision between the umbilicus and 
the ensiform cartilage. Pancreatic fluid may be septic ; therefore great 
care must be taken not to infect the general peritoneal cavity. The 
incision into the cyst should be large enough to permit thorough explor- 
ation for stone. Drainage must be used until the discharge cease. 
New growths of the pancreas may be sarcomata or carcinomata. 
Sarcoma is very rare. Cancer of the pancreas may be primary or 
secondary. It is usually of the scirrhous form, and situated in the 
head of the gland. New growths limited to the pancreas are seldom 
suspected, excepting when a persistent cholcemia suggests their presence. 
Symptoms of Cancer of the Pancreas.—Epigastric pain with 
progressive emaciation and cachexia, jaundice, diabetes, and fatty diar- 
rhoea suggest malignant disease at the head of the pancreas. The symp- 
toms, however, are variable. A deep-seated, movable tumor in the 
region of the pancreas may confirm the diagnosis. 
Cancer of the pancreas must be differentiated from cancer of the pylorus, 
cancer of the liver and gall-bladder, cancer of the intestines, and impacted gall-stones. 
It is often impossible to make a differential diagnosis between a gall-stone impacted 
in the common duct and cancer of the head of the pancreas. 
Treatment.—Radical excision of malignant disease of the pancreas 
offers great technical difficulties and slight chance of permanent cure. 
It should be attempted only in cases in which the disease is limited to 
the tail of the gland. Palliative treatment should be directed to the 
relief of the persistent jaundice. The operation demanded in these 
cases is chole-cyst-enterostomy. The anastomosis should be made, if 
possible, between the gall-bladder and the duodenum. 
The Spleen. 
(For Wounds and Injuries of the Spleen see p. 341.) 
Suppurative Splenitis; Abscess and Gangrene of the Spleen.—The 
chief causes of suppuration of the spleen are septic embolism or infarcts, 
septic infection from without or within after injuries, and the extension 
of sepsis from neighboring organs. Diffuse abscesses of the spleen are 
uncommon. The process is usually circumscribed. In several pysemic 
conditions hemorrhagic infarcts of the spleen are not uncommon. 
Single or multiple abscesses, small in size, may enlarge and coalesce into 
a single large abscess sac involving the whole organ. Perisplenitis may 
result with adhesions to surrounding parts, which may guide the pus 
into the abdominal or thoracic cavity, the stomach, or intestines. Primary THE SPLEEN. 
397 
suppurative splenitis occurring in malarial or typhoidal conditions is 
caused by septic infection of an organ the vitality of which has been 
weakened by constitutional disease—an organ made still more susceptible 
by vascular engorgement. 
The symptoms of splenic abscess are vague. Unless the capsule is 
involved, pain will not be present. Though hectic fever may result, it 
is of little value as a symptom, because splenitis is usually secondary to 
a general febrile disease. The vomiting of pus or blood or its passage 
in the stools may occur, though rarely. 
The chief points of diagnosis are enlargement and tenderness of 
the spleen, and possibly the presence of fluctuation. The majority of 
cases result fatally, before the condition is suspected. When an abscess 
of the spleen can be made out, incision and drainage are indicated. 
Aspiration of the spleen is dangerous and should seldom be attempted. 
Gangrene of the spleen is the result of intense septic infection of 
the spleen. Its course is so rapid and fatal that surgical treatment 
is rarely if ever indicated. 
Displacement of the Spleen.—Stretching of the ligaments of the 
spleen allows change in the normal position of the organ. Extreme 
changes in position other than traumatic prolapse and dislocation are 
found whenever chronic enlargement of the spleen has caused abnormal 
stretching of the ligaments. In rare cases the elongation of the liga- 
ments may be congenital, but usually the condition is gradually acquired. 
Ultimately the spleen may be found in the hypogastric or umbilical 
region, the iliac fossae, or the pelvis. The chief cause of wandering- 
spleen is hypertrophy. 
The symptoms of wandering spleen are those of dragging of the 
enlarged organ upon the stomach and the pancreas, the circulation of 
which, as well as of the spleen itself, may be impaired. The splenic 
ligament in extreme cases becomes stretched into a long pedicle, the twist- 
ing of which has been known to cause gangrene of the spleen. Pain 
may be constant; it is produced by dragging on the stomach or pancreas 
or by dragging on adhesions to other organs. 
The diagnosis is to be made from the characteristic shape of the 
splenic tumor, with the recognition of the hilum. The normal area of 
splenic dulness is replaced by an area of tympany. In most cases of 
wandering spleen the size of the tumor far exceeds the normal size 
of the gland. 
The treatment of this affection may be palliative or operative. A 
trial of palliative measures should be made when the mobility is slight 
and the symptoms are mild. With the patient in the dorsal decubitus the 
spleen should be held in normal position by means of compresses and 
ice-bags. If the hypertrophy of the displaced spleen be due to malaria, 
an attempt to reduce the size of the organ by medical treatment may be 
made. Except in one or two instances, splenectomy has been the only 
means of radical cure. The mortality of splenectomies for this cause 
has been slight. (For the operation of splenectomy see page 398.) 
Hypertrophies and Tumors of the Spleen.—Hypertrophies of the 
spleen, aside from the acute enlargement occurring in the course of infec- 
tious diseases, are (1) simple or idiopathic; (2) malarial; (3) leuksemic 
and pseudo-leuksemic. 398 
SURGERY OF THE ARDOMEX. 
Idiopathic hypertrophy of the spleen is a chronic hyperplasia 
occurring without changes in the blood or the lymph-nodes. The eti- 
ology is obscure. 
The diagnosis of idiopathic hypertrophy can only be made after 
eliminating other possible causes of hypertrophy. Chronic malaria is the 
commonest cause. Leuksemic and pseudo-leuksemic enlargements of the 
spleen are secondary to morbid changes in the blood- and lymph-systems. 
Leuksemic conditions absolutely contraindicate surgical interference. 
Chronic enlargement of the spleen occurs also in cirrhosis and other 
chronic diseases of the liver, in chronic pulmonary diseases which cause 
passive congestions, in syphilis and amyloid diseases. Surgically it is 
unimportant. 
New Growths of the Spleen.— Cancer and sarcoma of the spleen 
are very rare, and are usually secondary growths, though cancer has 
been known to be primary in the spleen. Cysts of the spleen may be 
simple serous cysts, blood-cysts, or hydatid cysts. Cysts which contain 
blood or serous fluid are of anatomical rather than of surgical interest, 
and rarely justify operative interference. 
The splenic cyst is usually due to the echinococcus. The development of the 
cyst is slow, and the symptoms are entirely those of pressure—pain in the back 
and left flank, the sensations of pressure on the stomach and intestines. The 
diagnosis is impossible except in the presence of a tumor. Differential diagnosis 
must be made between hydronephrosis, new growths, and cysts of the ovary and the 
pancreas. A hydatid bruit and fluctuation maybe present. When exploration of 
a splenic tumor is demanded, laparotomy rather than aspiration is indicated, on 
account of the liability to hemorrhage and extravasation from the use of the 
needle. 
Operative Treatment of Splenic Tumors.—Because of the 
uncertainty of diagnosis in cases of splenic tumor the surgeon can never 
know before exposing the spleen whether a splenotomy or a splenectomy 
must be performed. The choice depends upon the appearance of the 
organ after exposure and the results of aspiration. The operation of 
splenotomy should be reserved for cases of cyst and of abscess. 
Laparo-splenotomy formerly meant extirpation of the spleen, but at 
present its use is restricted to cases in which a cyst or abscess of the 
spleen is drained through an incision. The incision should be made at 
tlie border of the ribs, over the most prominent portion of the tumor. 
The chief care in the operation is the prevention of a general septic peri- 
toneal infection. Adequate drainage of the abscess-cavity should be 
provided by means of tubes and gauze. 
Splenectomy has been performed for leukaemic hypertrophy, mala- 
rial hypertrophy, simple hypertrophy and wandering spleen, cysts of the 
spleen, malignant disease, abscess and inflammatory changes, syphilis 
and amyloid degeneration, wounds and ruptures. 
Surgical interference in leukaemic enlargement of the spleen is contraindicated, 
with the possible exception of those cases in which the changes in the blood and 
in the lymph-system are slight and the splenic tumor large. Practically, splenec- 
tomy is justifiable in simple or malarial hypertrophy, in wandering spleen, in cyst, 
in abscess, wounds, and ruptures, and rarely in cases of malignant disease. 
The incision for splenectomy should be made on the left side of the 
abdomen along the border of the ribs. The situation and extent of the 
incision should in all cases be such as to facilitate the securing of the SURGERY OF THE LIVER. 
399 
splenic artery, for the chief danger in the operation is hemorrhage. The 
incision should be made large enough to admit the hand, in order that 
thorough exploration of the tumor and its attachments may be made. 
The pedicle should be tied with large silk, and if bloodless may be 
dropped into the abdomen. Venous hemorrhage should be controlled 
by ligatures and gauze packing. 
Splenopexis, for securing the wandering spleen in its normal posi- 
tion by means of sutures, has recently been advocated as a routine 
treatment by Rydygier. At present no opinion as to the value of the 
operation can be expressed. 
Surgery of the Liver. 
(For Wounds and Injuries of the Liver see p. 341.) 
Displacements of the Liver.—Congenital displacements of the liver 
may be either transposition of the entire organ, as in situs transversus, 
or hernia of the liver into the abdominal cavity through some defect in 
the abdominal wall (see Fig. 186 in Chapter IX.), or into the thoracic 
cavity through a deficiency in the diaphragm. 
The normal liver, within certain limits, is freely movable, rising or 
falling with intra-thoracic or intra-abdominal pressure. Stretching of 
the ligaments of the liver, especially the suspensory ligament, occasionally 
results in abnormal displacement of the liver or what is called float- 
ing liver. This lesion is four times as common in women as in men. 
The chief cause is repeated pregnancies, associated with pendulous 
abdomens. The only symptoms are those of pressure—dyspnoea, nausea, 
vomiting, cyanosis, and occasionally jaundice. 
The diagnosis may be made from the characteristic shape of the 
tumor and the presence of tympany in the usual area of liver dulness; 
also from the ease with which the tumor may be replaced in the normal 
position of the liver. 
The only treatment should be the application of bandages to hold 
the organ in place. 
Abscess of the liver is due to invasion by septic organisms. Trau- 
matism—contused, lacerated, or penetrating wounds—is a predisposing 
cause. Abscesses of the liver may be of the solitary or tropical form, the 
multiple embolic or pycemic form ; they may result from gall-stones or from 
suppuration in the bile-ducts. Rarely foreign bodies may pass from the 
stomach or the intestine into the liver and cause suppuration. Intestinal 
round-worms are a possible cause of abscesses in the liver, especially 
in children. 
The bacteria of suppuration gain access to the liver through the circulatory or 
biliary systems (colon bacillus). The main route of infection is by the portal 
vein, through which infective processes in the intestinal tract become a frequent 
cause of hepatic abscess. 
The solitary or tropical abscess is most frequent in hot climates. It may be 
single or double, but is never multiple. The abscess-cavity may involve nearly 
the whole liver, but in about 70 per cent, of the cases it affects the right lobe only. 
The infection is generally of dysenteric origin, due to the invasion of the amoebae 
coli from the intestinal tract. The suppurative process may be limited by encap- 
sulation, in which case the pus is generally sterile. 
Hepatic abscesses may rupture into the lungs, the pleurae, the 400 
SURGERY OF THE ABDOMEN. 
pericardium, the peritoneum, the intestines, the bile-ducts, or the gall- 
bladder, or they may perforate externally. 
Multiple abscesses of the liver are always secondary to a septic focus elsewhere. 
They may be caused by gastric or typhoid ulcers, by fissure or ulceration of the 
rectum, by appendicitis, and by injuries to or operations upon the head. This 
disease is always associated with severe pysemic symptoms, the infectious process 
taking the form of a suppurative pylephlebitis. Section of the liver will show 
multiple collections of pus in direct communication with the branches of the 
portal vein. 
Extension of suppurative processes from the gall-bladder or from the gall- 
ducts may lead to a general suppuration in the liver—a lesion not associated with 
so rapid or so severe a general sepsis as is the case in embolic abscesses. Hepatic 
abscess is sometimes, though very rarely, coincident with, if not dependent upon, 
cancer of the liver. Without exploration the complication can be only suspected. 
Diagnosis.—In contusions and penetrating wounds of the liver 
septic infection can be detected by the usual signs of localized peritonitis 
—pain, tenderness, and fever. 
In some cases of solitary abscess the disease may be latent and the 
lesion unsuspected. The chief symptoms of single abscess of the liver 
are hectic fever, rigors, marked general sepsis, and profuse sweating. An 
enlargement of the liver usually appears on the upper surface and in the 
right lobe, associated with tenderness on palpation and pain in the right 
hypochondrium, radiating into the right back and shoulder. Jaundice 
is rare. 
The symptoms of multiple embolic abscesses are those of pyaemia, 
associated with an enlarged and tender liver. The general course of 
pyaemic abscesses of the liver is severe and the prognosis grave. 
Abscess of the liver must be differentiated from intermittent malarial 
fever, hydatid cyst of the liver, abscess of the abdominal wall, cancer of 
the liver, gall-stones, dilated gall-bladder, and right-sided pleurisy. 
Examination of the blood for the organism of malaria is an important 
means of differentiation. 
The diagnosis is confirmed by the presence in the stools of the 
amoebae coli of dysentery. Cholelithiasis, with dilatation of the gall- 
bladder, is accompanied by a history of gall-stones, by paroxysmal pain, 
and by jaundice. The constitutional symptoms are much less severe. 
Hydatids are rare ; their growth is slow. In the majority of cases there 
is no fever; pain conies on late and is not severe. The general condi- 
tion is but slightly changed. The fluid withdrawn by the aspirating 
needle is clear and may contain the booklets of the parasite. Suppu- 
rating hydatid cyst is with great difficulty distinguished from abscess of 
the liver. Cancer of the liver is generally a secondary growth. Jaundice 
is usually present and hectic fever absent. The tumor is hard and 
nodular. When cancer is associated with abscess its presence may not 
be suspected. Right-sided pleurisy, with effusion, must be diagnosti- 
cated by physical signs. Abscess in the abdominal wall gives no history 
of intestinal disturbance and presents less evidence of general sepsis. 
Treatment.—Cases of solitary abscess or of suppuration following 
traumatism are the only ones in which surgical interference should be con- 
sidered. The severe pysemic condition and the dissemination of the pus- 
foci in multiple embolic abscesses contraindicate operation. The cases 
are almost invariably fatal. If from the presence of an external tumor SURGERY OF THE LIVER. 
401 
and from constitutional signs abscess of the liver is evident, the sur- 
gical treatment should be free incision and drainage. Thorough digital 
exploration should be made in search of possible sacculations and 
secondary abscess-cavities. Hemorrhage should be checked by gauze 
packing. The after-treatment is that of any internal abscess-cavity. 
The results in operated cases have been excellent. 
Hydatid Cysts of the Liver (Fig. 177).—Hydatid disease is rare in 
America. The liver is the organ most frequently alfected. The parasites 
reach the liver from the intestinal tract by the way of the portal vein. The 
growth of hydatid cysts of the liver is very slow, from four to twenty- 
live years being the duration of their life. In many cases the cyst never 
attains sufficient size to cause symptoms; in many the disease is self- 
limited and the cyst becomes calcified. 
From pressure in the region of the liver 
large cysts cause pain and a feeling of 
weight; from pressure on the dia- 
phragm, dyspncea and cough; from 
pressure on the portal vein or bile-duct, 
ascites, jaundice, and enlargement of 
the spleen. The cyst may rupture into 
the pleurae or lungs, into the perito- 
neum, or externally. Spontaneous cure 
has resulted from perforation into the 
intestinal tract. The general condition 
is usually but little affected. When 
suppuration in the cyst-fluid occurs, the 
symptoms suddenly become those of 
hepatic abscess. 
The diagnosis may be impossible 
unless the cyst is such as to be easily 
palpated through the abdominal wall. 
The cysts, especially when multi- 
locular, are sometimes of great size 
(Fig. 177); frequently their irregu- 
larity in shape may suggest the nature 
of the disease. A painless enlargement 
in the liver, a fluctuant and tense 
tumor, and an occasional hydatid fre- 
mitus are suggestive signs. The disease has been mistaken for can- 
cer, for hydronephrosis, for dilatation of the gall-bladder, for right- 
sided pleural effusion, and for abdominal aneurism. The tumor of an 
enlarged gall-bladder is pear-shaped, and is usually accompanied by 
a history of gall-stones or of catarrhal or obstructive jaundice. In 
cysts of the kidney the colon lies in front of the tumor; in hydatid cysts 
of the liver it lies behind. A cyst of the liver moves with respiration. 
When the diaphragm is pushed up by the pressure from hydatid cyst of 
the liver, the heart will be found more displaced than in cases of pleural 
effusion. In some instances it may be necessary to resort to the aspirating 
needle to establish the diagnosis. 
Treatment.—When hydatid cysts of the liver are large enough to 
be diagnosticated with a fair degree of certainty, operation should be 
Fig. 177. 
Hydatid cysts of a monkey’s liver (Warren 
Museum). 402 
SURGERY OF THE ABDOMEN. 
performed. Aspiration, except as a diagnostic measure in obscure cases, 
is not to be advised, not only because of the dangers attending it, 
but because it will not remove the mother cyst. Electrolysis and injec- 
tions of iodine have been tried without permanent success. In draining 
a hydatid cyst the incision should be made over the most prominent part 
of the tumor, the peritoneum cautiously opened, and the tumor exposed. 
Adhesions of the cyst to the parietal peritoneum are rarely found. After 
thoroughly walling off the general peritoneal cavity with gauze the ten- 
sion of the cyst may be cautiously relieved by removing some of the 
fluid with the aspirating needle. After the cyst-cavity has been thor- 
oughly evacuated through free incision and digital exploration, its 
wall should be stitched to the parietal peritoneum and the sac packed 
with gauze around drainage-tubes. The after-treatment consists in 
thorough antiseptic irrigation. 
Total excision of a large hydatid cyst has been reported, as well as ex- 
cision of several small cysts. The difficulties and dangers from hemorrhage 
in such a procedure contraindicate its adoption as the routine method 
of treatment. 
Tumors of the Liver.—The forms of new growth found in the 
liver are carcinomata, sarcomata, angeiomata, gummata, and lymphomata. 
They are rarely, if ever, amenable to surgical treatment. Malignant 
growths in the liver are usually secondary. A few instances have been 
reported in which extirpation of primary sarcomatous or carcinomatous 
nodules in the liver has been attempted. The disease, however, has 
always rapidly returned, either in the liver or elsewhere. 
Simple serous and dermoid cysts are occasionally found in the liver. 
When of sufficient size to be noticed they should be treated in the same 
way as hydatid cysts of the liver. 
Malformations of the Gall-bladder.—Congenital absence of the 
gall-bladder and variations in the size and situation of the intestinal 
opening of the gall-duct have occasionally been noted. 
Gall-stones are a common affection of middle and advanced 
life. Three-fourths of all the cases are found in women. Gall-stones 
are usually formed in the gall-bladder, very rarely in the small branches 
of the hepatic duct in the liver itself. Their formation probably is 
associated with some slowing of the biliary flow and with catarrhal 
disease of the mucous membrane. So long as gall-stones remain in the 
gall-bladder thev may cause no symptoms. The pathological effects of 
gall -stones are—biliary colic, due to the passage of stones through the 
ducts, obstruction of the ducts, and septic invasion, leading to suppuration 
in the gall-bladder and ducts, to ulceration, perforation, abscess of the 
liver, etc. 
Symptoms.—Paroxysmal attacks of pain, with or without brief 
jaundice, followed by periods of complete remission, point to the 
passage of gall-stones through the cystic duct. Persistent pain, with 
more or less persistent jaundice, indicates the slow passage of a biliary 
calculus from the gall-bladder through the common duct to the duo- 
denum. 
Cholelithiasis and Surgery of the Gall-bladder. CHOLELITHIASIS AND SURGERY OF THE GALL-BLADDER. 
403 
The diagnosis of gall-stone colic is generally easy, but it must be 
expected that at times cancer in the vicinity of the gall-bladder will be 
found associated with calculi. A certain percentage of cases, mainly 
the cases of the passage of stones through the cystic duct, have no 
jaundice. In these cases the diagnosis is not so evident. Youth in a 
patient makes the existence of malignant disease improbable. 
Complete obstruction of the cystic duct from impaction of a stone or from other 
causes may result in a dilatation of the gall-bladder, which may attain enormous 
proportions. The tumor may fill the entire right half of the abdomen and even 
extend into the pelvis. In long-continued obstruction the fluid contents of the 
gall-bladder may be clear or slightly tinged with bile. Septic infection may take 
place, and cause empyema of the gall-bladder. A dilatation of this sort must be 
differentiated from cystic tumors of the kidney, pancreas, ovary, or mesentery. 
Dilatation of the gall-bladder from the impaction of calculi in the cystic duct is 
unattended by jaundice. 
Impaction in the common duct usually causes marked dilatation 
of the gall-bladder; it causes dilatation of the branches of the hepatic 
duct, and may result in pronounced and fatal jaundice. Infection of the 
mucous membrane of the gall-bladder or of the biliary ducts may occur 
at any time through minute injuries to the epithelium. The usual forms 
of bacteria are the bacillus coli communis, the streptococcus, and various 
staphylococci. Infection through the cystic duct may cause empyema 
of a dilated gall-bladder; it may convert a catarrhal cholangitis, the 
Fig. 178. 
Gall-bladder contracted upon a gall-stone (Warren Museum). 
usual accompaniment of gall-stone impactions in the common duct, into 
a suppurative cholangitis, from which abscess of the liver may result. 
Acute phlegmonous cystitis may occur as an indirect sequence. The 
so-called hepatic fever commonly ascribed to chronic catarrhal cholangitis 404 
SURGERY OF THE ABDOMEN. 
of the common duct is probably due to septic causes. The septic process 
may cause ulceration and perforation of the gall-bladder or its ducts; 
it often extends to the peritoneal coats, causing firm adhesions of the 
gall-bladder to neighboring structures. It is not uncommon to find the 
gall-bladder thickened and contracted upon a large stone (Fig. 178), 
buried in firm adhesions extending to the colon, the duodenum, or the 
pylorus. Such adhesions greatly increase the difficulties of operations 
upon the gall-bladder. 
Perforation of the gall-bladder or ducts from the ulceration of 
calculi or from rupture may result in external or internal fistulse, or 
in direct extravasation into the general abdominal cavity, with general 
or local peritonitis (Fig. 179.) Perforation may take place into the 
Fig. 179. 
Perforating ulcer of the gall-bladder causing death from peritonitis (Warren Museum). 
pleura or into the lung. Internal biliary fistulie have been found 
between the gall-bladder and the intestines; rarely between the gall- 
bladder and the stomach, and still more rarely between the gall- and 
the urinary bladder; in the majority of cases perforation takes place into 
the duodenum. Large gall-stones not infrequently ulcerate into the intes- 
tinal tract and become a cause of acute obstruction. 
Strictures in the common duct, and also in the cystic, usually 
originate from an old gall-stone impaction through the cicatricial con- 
traction of the injured mucous membrane ; they may be occasionally 
due to catarrhal or diphtheritic ulceration. 
The diagnosis of biliary colic must be made from the paroxysmal CHOLELITHIASIS AND SURGERY OF THE GALL-BLADDER. 
405 
nature of the attacks, with or without jaundice. The discovery of a 
gall-stone in the faeces will positively establish the diagnosis. Persistent 
pain and jaundice, following a history of a number of paroxysmal 
attacks, point to a stone in the common duct. When the chief symp- 
tom is jaundice, the diagnosis between a stone impacted in the common 
duct and malignant disease may be impossible. Indeed, cancer often 
complicates retained or impacted gall-stones. Exploration often shows 
that the jaundice is caused by the pressure of a malignant growth upon 
the common duct. Malignant disease, situated in the head of the pan- 
creas and obstructing the biliary flow, most closely simulates an impacted 
stone. Obstruction of the duct by the pressure of non-malignant growths 
cannot be absolutely diagnosticated. Symptoms of jaundice and emaci- 
ation may be the result of a complete obstruction of benign origin, of 
hopeless intra-hepatic disease, or of the pressure of an extra-hepatic malig- 
nant growth. The completeness of the biliary obstruction is important. 
In many forms of intra-hepatic disease attended by jaundice there is a 
slight amount of biliary secretion, which makes its way into the intestine 
and may be found on examination of the faeces. In mechanical obstruc- 
tion, on the other hand, the biliary flow is totally shut off by occlusion of 
the bile- or common ducts and the faeces contain no bile. Moreover, in 
a mechanical obstruction there may be temporary relaxation of the pres- 
sure causing it, with sudden appearance of bile in large quantities in the 
intestinal tract. 
Cystic tumors of the kidney, pancreas, stomach, ovary, omentum, or mesentery, 
and hydatid cysts of the liver may at times be confounded with dilated gall-bladder 
unaccompanied by jaundice. The shape, location, and mobility of the tumor, with 
the evidence gained by aspiration, throw light upon the diagnosis. In some cases 
the diagnosis can be made only by exploratory operation. 
Indications for Operation.—Prolonged pain in the region of the 
gall-bladder, cliokemia without pain and without positive evidence of 
organic disease, and paroxysmal pain, with the discovery of gall-stones 
in the faeces, are conditions demanding operative interference. Distinct 
evidences of malignant disease, such as nodular masses in the liver, with 
cachexia, contraindicate operation, except for the relief of pain, and then 
only when gall-stones are diagnosticated. Marked diminution in the 
size of the liver, associated with ascites, contraindicates interference. 
Surgical Treatment.—Cholecystotomy.—This operation con- 
sists in incision of the gall-bladder. The gall-bladder is first sewed into 
the abdominal wound; it may be incised at once, or the opening may be 
deferred for two or three days. Ideal cholecystotomy for gall-stones 
consists in opening the gall-bladder immediately, removing the stone, 
closing the wound in the gall-bladder by interrupted Lembert stitches, 
replacing it in the abdominal cavity, and closing the abdominal wound. 
When practicable, this is a better method than that of leaving the gall- 
bladder open with permanent drainage, because a biliary fistula is thereby 
avoided. After drainage, the flow of bile may persist for many months 
and necessitate a second operation to close it. When the gall-bladder is 
so contracted that it cannot be sutured into the abdominal wound, incision 
with drainage or total extirpation may be performed. The method of 
drainage consists in the use of rubber drainage-tubes surrounded by 
gauze. 406 
SURGERY OF THE ABDOMEN. 
Cholecystectomy.—Extirpation of the gall-bladder is desirable 
when its walls are thickened and friable and contracted upon one or 
more stones. The stones may be removed and extravasation may be 
avoided by tying off and removing the gall-bladder, stones and all. This 
procedure should not be attempted unless the gall-bladder can be sepa- 
rated easily from adjoining structures. Drainage is a wise precaution 
after this operation. 
In malignant disease of the gall-bladder total extirpation is the only 
operation offering any chance of permanent cure. The operation is justi- 
fiable only when the disease is limited to the gall-bladder. 
Operations upon the Cystic, Hepatic, and Common Ducts.—Few 
conditions of the cystic duct admit of operative manipulation. Removal 
of calculi in this duct by incision, if possible, is preferable to pro- 
longed manipulation with the hands or with forceps. Operations upon 
the hepatic and common ducts are indicated when stones are impacted 
in either, and cannot be removed by dilatation of the cystic duct or by 
reasonable efforts at crushing. Care must be taken when making the 
incision to avoid the hepatic artery and the portal vein. After being 
incised, the ducts should be carefully closed with sutures. 
The possibility of performing this operation will depend upon the build of the 
patient, the thickness of the abdominal wall, the depth of the wound, the number 
and firmness of adhesions, the reflections of the normal peritoneum, and the con- 
dition of the duodenum, stomach, and colon. Even when the sutures have been 
accurately applied provision for leakage of bile must be made. In all operations 
on the gall-bladder or ducts great care must be taken to avoid contamination of 
the peritoneum with bile. 
Cholecystenterostomy.—In chronic, organic, non-calculons obstruc- 
tion between the liver and the duodenum, in order to avoid a chronic 
and fatal chohemia provision must be made for the artificial escape of 
bile, either externally or into the intestine. Anastomosis between the 
gall-bladder and the duodenum is to be preferred, but when the local 
anatomical conditions render this impossible deviation of the bile-flow into 
the colon may be effected. Anastomosis may be made without the aid 
of mechanical devices or with the aid of Sen ifs plates or the Murphy 
button. Many cases of the successful performance of this operation 
with the Murphy button have been reported within the last two or three 
years. 
If for any reason the gall-bladder cannot be utilized in making the anastomo- 
sis, in some cases the common duct may be isolated above the obstruction and 
fastened into the duodenum or the colon. Such a procedure maybe possible when 
the obstruction is near the duodenum. Operations upon the common duct by way 
of the internal surface of the duodenum may be practised under exceptional cir- 
cumstances. Organic obstructions situated in the hepatic duct, above the juncture 
with the cystic, admit of no relief, except occasionally by the formation of a biliary 
fistula above the constriction. CHAPTER IX. 
HERNIA. 
Maurice H. Richardson, M. D. 
The protrusion of an internal organ through a congenital or an 
acquired opening in confining structures is called hernia of that organ. 
The term hernia must be qualified to denote the organ involved, as 
hernia cerebri, hernia testis, etc. Hernia used alone means, as a surgical 
term, a protrusion of the intestine, of the omentum, or of both from the 
cavity of the abdomen through some defect in its parietes. 
Hernke are best classified according to their anatomical situation : 
Congenital, 
F unicular, 
Infantile, 
Acquired. 
Acquired. 
Indirect, 
Inguinal, 
Femoral. 
Direct, 
Congenital, 
Infantile, 
Acquired. 
Umbilical, 
r Epigastric. 
As the result of laparotomy 
or other wounds. 
As the result of congenital 
failure of development. 
Ventral hernia and hernise in the linea 
alba (other than umbilical), 
V 
Congenital, 
Acquired—Traumatic. 
Diaphragmatic, 
Gluteal or Ischiatic. 
Obturator. 
Perineal. 
Lumbar. 
Sacro-rectal. 
Retroperitoneal. 
Proper itoneal. 
Hernise are either congenital or acquired. Congenital hernise are 
caused by developmental defects in the peritoneum or in the abdominal 
wall. The chief cause of acquired hernia is increased abdominal pres- 
sure, constant or intermittent. Acquired hernise may be of slow or of 
sudden development. Increased abdominal pressure may be due to— 
1. Occupation (involving sudden and severe exertion, especially in 
a stooping posture). 
2. Pregnancy (pressure upon and weakening of the abdominal wall). 
407 408 
HERNIA. 
(a) Chronic lung affections (cough); 
(ib) Stricture of the urethra (straining); 
(c) Prostatic hypertrophy or urinary calculus (straining) ; 
(d) Phimosis (straining); 
(e) Constipation (straining); 
(/) Ascites (pressure upon and weakening of the abdominal 
walls); 
(g) Abdominal tumors (pressure upon and weakening of the 
abdominal walls). 
Other causes contribute more or less directly to the production of 
hernia. Among them are simple weakness of the abdominal walls, 
trauma, and surgical operations. 
3. Disease— 
Trauma, except as a cause of strain, rarely causes hernia. It may, however, 
produce a ventral hernia by direct rupture of the abdominal muscles. Laparotomy 
wounds are prolific sources of ventral hernia, especially those which cannot be 
immediately closed because of the necessity for drainage. Even in abdominal 
incisions which are immediately sutured, and which heal by first intention, a very 
considerable number of herniae result. 
Anatomically a hernia consists of the sac (peritoneum), the contents 
of the sac (bowel, omentum, or both), and its external coverings (muscles, 
fasciae, and skin). 
The sac is formed of peritoneum which is pushed ahead by the 
abdominal pressure exerted upon the protruding viscus, usually intes- 
tine and omentum. There is at first a bulging of the peritoneum, then 
a conical protrusion, which more and more effectively dilates the weak- 
ening parietes. As soon as the dilatation is sufficiently large, a coil 
protrudes and pushes its way, with greater rapidity than before, among 
the less resistant structures of the abdominal wall. The escape through 
the muscular and aponeurotic layers is doubtless gradual and impercept- 
ible ; among the outer layers, rapid and conspicuous. Hernial tumors 
that suddenly appear after violent exertion have doubtless already made 
their way through the inguinal canal to the external ring; as, for exam- 
ple, inguinal hernia. 
The physical appearance of the sac depends upon the age of the hernia, the 
degree of distention, the amount of irritation, etc. It may be opaque and thick- 
ened or translucent and thin, smooth, here and there constricted, easily separated 
from surrounding structures or intimately adherent to them. 
In congenital hernice the peritoneal pouch exists at birth ; in acquired, 
it is formed by pressure through natural or accidental openings in the 
abdominal parietes. When the contents of the sac consist solely of 
intestine, the hernia is called an enterocele; when they are made up of 
omentum, an epiplocele ; when of both intestines and omentum, an entero- 
epiplocele. 
The structures that cover the hernial sac vary with the locality of the hernia. 
They consist of fasciae, tendons, muscles, and skin. Anatomically these layers are 
distinct and traceable to definite structures derived from the abdominal wall; sur- 
gically they are indefinite, and, except the most characteristic, seldom distin- 
guished. 
The escape of abdominal viscera may cause at times not even annoyance; it 
may be attended by discomfort, and at times by severe pain. A simple reducible 
hernia may escape the patient’s attention until a tumor is discovered or the pain 
of strangulation begins. (See Strangulated Hernia.) DIAGNOSIS OF HERNIA. 
409 
The physical evidence of hernia consists in a tumor, more or less 
marked, at one of the usual seats of hernia. In size hernial tumors 
vary within extreme limits (Fig. 180). In the inguinal variety a scrotal 
tumor may reach to the knees without serious symptoms; a fatal stran- 
gulation may occur without a perceptible tumor. Umbilical and ventral 
hernise sometimes attain enormous dimensions, and contain so large 
a proportion of the abdominal contents that the abdominal cavity in 
the course of years becomes too small to contain them on attempted 
reduction. 
The Diagnosis of Hernia.—Hernia in general is recognized by the 
presence, at one of the usual seats of the lesion, of a painless tumor, 
which disappears in the recumbent posture and reappears in the erect; 
which even in the erect position can be replaced; which may be tym- 
panitic, and which disappears with a gurgle. (For the diagnosis of 
special hernise see Special Hernise.) 
The physical examination of a hernia should be made with the 
patient in the erect and then in the recumbent posture. The tumor 
should be palpated, percussed, and auscultated. (See Special Hernise.) 
The contents of a hernial sac may be easily returned to the abdominal 
cavity or they may be permanently fastened in the sac ; they may become 
distended with impacted fecal masses; they may, with the sac, become 
inflamed ; or they may become necrotic from the cutting off of the blood- 
supply. 
Hernia clinically considered with reference to these conditions may 
be— 
1. Reducible. 
2. Irreducible. 
3. Incarcerated or obstructed. 
4. Inflamed. 
5. Strangulated and gangrenous. 
(a) A reducible hernia is one in which the contents of the sac can be 
readily returned to the abdominal cavity. Such a hernia appears as a 
rounded or pear-shaped tumor, usually soft and inelastic on palpation, 
tympanitic on percussion. It receives a perceptible impulse when the 
patient coughs; it is reduced with a distinct slip and gurgle. A re- 
ducible omental hernia suggests a superficial lipoma; it is dull on per- 
cussion, somewhat lobulated, and resistant on palpation. It gives a 
moderately marked impulse when the patient coughs; it is reduced 
slowly and without gurgle. The recognition of a reducible hernia made 
up of both omentum and intestine is often difficult. 
(b) A hernia is irreducible when the contents of the sac cannot be 
returned into the abdominal cavity. Herniae may become irreducible, 
first, from their large size; secondly, from adhesions between the sac 
and a portion of its contents; thirdly, from an excessive development 
of fat in the prolapsed omentum. 
(c) A hernia is obstructed or incarcerated when the bowel in the sac 
of an irreducible hernia becomes obstructed by impacted faeces. It is 
usually seen in the aged, and is most common in the umbilical variety. 
An incarcerated hernia is dull on percussion, gives impulse on cough- 
ing, and is associated with obstipation, nausea, and vomiting; it is with- 410 
HERNIA. 
out the severe symptoms of intestinal obstruction and bowel-necrosis 
seen in strangulation. 
(d) An inflamed hernia is the result of violence, most often from the 
pressure of a badly-fitting truss. The parts are tender, red, and 
swollen ; the hernia is irreducible. Nausea, vomiting, and pyrexia are 
present to a slight degree; but here, as in incarcerated hernia, the 
severe constitutional symptoms of acute obstruction and bowel-necrosis 
are absent. 
(e) Strangulated and Gangrenous Hernia.—The strangulation of pro- 
truded gut or omentum begins whenever from unusual crowding into 
the hernial sac or from other causes the return of venous blood is 
impeded. Passive congestion then makes the bowel or omentum oedem- 
atous, increases the pressure within the sac, and augments each 
moment the disastrous action of the constricting ring. Venous stasis 
becomes complete. The arterial supply is next impeded, and finally cut 
off* entirely. This interference with circulation causes necrosis of the 
constricted portion, which becomes gangrenous through the invasion 
of intestinal bacteria. Necrotic changes begin in the mucous mem- 
brane at the point of constriction. If the strangulation is unrelieved, 
the gangrenous process extends to the serous covering of the intestine, 
and eventually results in perforation. In the first hours the hernial 
sac becomes distended by exudation, the intestinal coils shrunken and 
dark colored. The exudate into the sac, sterile only in the early hours 
of strangulation, soon becomes contaminated by the passage of bacteria 
through the altered bowel-wall. Above the ring the distal loop of intes- 
tine is usually empty and contracted ; the proximal, distended with 
liquid feces, becomes congested and oedematous, paretic and dilated. 
The constitutional symptoms of toxic absorption, aggravated by those 
of acute obstruction, as a rule, appear early—incessant vomiting, cold 
extremities, feeble and accelerated pulse, normal or subnormal tempera- 
ture, cyanosis, and exhaustion. At times the depth of the systemic 
depression is out of all proportion to the severity of the local lesion. 
Death sometimes takes place before the pathological changes in the 
strangulated gut have advanced sufficiently to cause necrosis and 
perforation of the prolapsed coil. The fatal result often seen in the 
early hours of a strangulated hernia is probably due partly to shock 
from acute obstruction and incipient necrosis, and partly to toxsemic 
absorption from pathogenic bacteria. 
Symptoms.—The symptoms of strangulated hernia are general, call- 
ing attention to the abdomen, and local, calling attention to a hernial 
tumor. The general symptoms are those of acute intestinal obstruction. 
They may come on suddenly, without premonition, or in gradually 
increasing peristaltic paroxysms. The general symptoms of simple 
mechanical obstruction become aggravated by those of septic absorption 
as soon as necrosis within the sac takes place. 
General peritoneal infections occur but rarely in strangulated hernia, being 
prevented by adhesions at the constricting ring. The effect of strangulation- 
necroses upon the patient varies with his susceptibility to infection and his 
powers of endurance. (See Acute Intestinal Obstruction.) Some patients suc- 
cumb in a few hours; others survive the constitutional and local strain of sponta- 
neous cure through a fecal abscess and artificial anus. DIA GNOSIS OF HERNIA. 
411 
The local signs of a strangulated hernia are at first confined to 
changes in the hernial tumor. The later local symptoms become 
merged in those of acute obstruction, with or without general peritonitis. 
The general symptoms of acute obstruction dependent upon a strangu- 
lated hernia are accompanied usually, though not invariably, by a tumor 
at one of the ordinary seats of hernia. The exception is seen when a coil, 
slightly protruding through a ring, is strangulated deep below a thick 
layer of fat. The tumor of strangulated hernia is tense, elastic, and incom- 
pressible. It is tender on palpation and dull on percussion. The dul- 
ness (fluid from passive congestion) may give place to tympanitic 
resonance if the effused fluid is slight and the intestine distended 
with gas. As a rule, however, most tumors of strangulated hernia 
Fig. 180. 
Scrotal hernia (Massachusetts General Hospital, Dr. H. H. G. Beach) 
are dull, not only from fluid transuded into the sac, but from fluid 
poured into the intestine itself. 
The color of a strangulated hernia varies from dark red to greenish 
gray. The different shades of red indicate generally a viable gut; 412 
HERNIA. 
green, a more or less complete gangrene. A dark wine color is the 
shade most commonly seen. Such a color means a viable intestine, 
and it is* replaced by fche bright red of an acute congestion as soon 
as (the strangulation is reduced. (See Treatment of Strangulated 
Hehnia.) ‘Plate'X. / 
A\x?il is hopelessly damaged if in addition to its shade of green it has 
a fecal odor or if there is a distinct fecal escape. At times the necrosis 
is limited to a small patch here and there; at other times the whole 
affected coil is melted into an offensive sloughing mass. 
Inguinal hernia (Figs. 181, 182) comprises 80 per cent, of all cases. 
It occurs usually in males, and most frequently in the early years of life. 
In inguinal hernia the intestine makes its way out of the external 
abdominal ring (Fig. 182), either by way of the internal ring and the 
inguinal canal or directly through the abdominal wall beneath the exter- 
nal ring. The former is called indirect inguinal hernia, the latter 
Fig. 181. 
Indirect inguinal hernia (bubonocele) (original). 
direct. Indirect inguinal hernia is either congenital or acquired ; direct 
inguinal hernia is always acquired. 
In the indirect form of inguinal hernia the protruding viscus may be PLATE X. 
Strangulated Inguinal Hernia; Intestine Discolored but still Viable. (Richardson.) 413 
INGUINAL HERNIA. 
confined in the inguinal canal above the external ring. Such a form is 
incomplete, and from its suggestive appearance is called a bubonocele 
(Fig. 181). 
Indirect inguinal hernia, appearing in the first few months of life, 
is of three varieties—congenital, funicular, and infantile or encysted. 
The occurrence of these three forms depends upon the extent and man- 
ner of closure of the vaginal process of the peritoneum, which in the 
later months of foetal life is carried with the descent of the testis through 
the inguinal canal into the scrotum. At birth this process is normally 
obliterated and replaced by a small fibrous cord. 
1. Congenital Inguinal Hernia.—In this form of inguinal hernia the 
vaginal process of the peritoneum remains open throughout its entire 
length (Fig. 183). 
Fig. 182. 
Scrotal hernia, showing the upper surface of the ring, with omentum entering it; the inner 
surface of the sac is exposed with its contents—omentum, and the relations of the latter to the 
testicle. The ring is closed by the prolapsed omentum, which is adherent so that no intestine 
can enter the sac (Warren Museum). 
2. Funicular hernia, or hernia into the funicular process. The vagi- 
nal process of the peritoneum in this variety of hernia is closed just above 
the epididymis, as shown in Fig. 184. 
3. Infantile Encysted Hernia.—The vaginal process has been closed 
at the internal inguinal ring ; the protruding intestine presses this septum 414 
HERNIA. 
into the lower portion, forming a sac of three layers of peritoneum, as 
will be seen in Fig. 185. 
The congenital forms of hernia may be present at birth; they may 
appear soon after birth, or, in rare instances, in adult life. Congenital 
hernia is not infrequently associated with a retained testis. In young 
Fig. 183. 
Fig. 184. 
Congenital inguinal hernia. 
Infantile or encysted hernia, 
Hernia of the funicular 
process. 
girls indirect inguinal hernia along the canal of Nock is the commonest 
form. 
4. Acquired Indirect Hernia.—In this form of inguinal hernia the 
sac has been pushed along the inguinal canal in front of the viscera. 
It rarely appears before adult life, for its development is generally slow. 
Indirect inguinal hernia may show itself, first, as a tumor above 
Poupart’s ligament outside of the external ring (bubonocele, Fig. 181). 
In most cases, however, it first appears at the external ring as a small, 
soft, painless, easily-reducible tumor, hardly perceptible except by 
digital examination through the invaginated scrotum. In neglected 
cases the tumor increases in size by pushing aside the elastic structures 
about it, until it fills and distends the scrotum (scrotal hernia, Figs. 180, 
182). 
The coverings of indirect hernia are derived from the muscles and 
aponeuroses of the abdominal wall, each structure giving a layer with 
a special name. For all practical purposes that taken from the peri- 
toneum, the sac, is the only one of importance. 
Between the sac and the skin lie the strata corresponding to the skin, the 
superficial fascia (dartos), the external oblique (intercolumnar), the internal 
oblique (cremasteric), the transversalis fascia (infundibuliform). With the excep- 
tion of the cremasteric, which may be recognized by bundles of longitudinal and 
looped muscular fibres, none of these intermediate layers can be easily recognized. FEMORAL HERNIA. 
415 
Their practical importance is so slight that they hardly deserve the space taken 
to name them. 
Direct inguinal hernia occurs in adult life, is usually of acute 
origin, and frequently becomes strangulated. The hernia takes place 
directly through the abdominal wall at the triangular depression formed 
by the deep epigastric artery on the outer side, the obliterated hypo- 
gastric artery on the inner side, and Poupart’s ligament below—the 
triangle of Hesselbach—and appears at the external abdominal ring. 
Diagnosis of Inguinal Hernia.—The close proximity of the ana- 
tomical seat of femoral hernia to that of inguinal necessitates careful 
recognition of important anatomical landmarks in making a differential 
diagnosis. The relation of the neck of the hernial sac to Poupart’s 
ligament, to the spine of the pubes, and to the deep epigastric artery 
must be determined in every case. Inguinal hernice emerge above Pou- 
part’s ligament, femoral hernice below it. 
Indirect inguinal hernise, unless very large, present an oblong prominence just 
above and parallel to Poupart’s ligament, starting at the internal ring. Direct 
inguinal liernise are usually small and nearer the median line. The deep epigas- 
tric artery lies to the inner side of the indirect variety, to the outer side of the 
direct. When the hernia is old and the ring large it is impossible to distinguish 
between the direct and the indirect varieties by the relative position of the rings 
or by the direction of the neck, because long-continued pressure approximates the 
two rings, bringing the one almost directly behind the other. If the epigastric 
artery can be felt, either before or during operation, its relation to the neck of the 
sac will demonstrate the variety of hernia present. Femoral hernise emerge 
beneath Poupart’s ligament, and are reflected upward upon the abdominal wall by 
the pubic portion of the fascia lata. 
Heruife in the inguinal region must be distinguished also from other 
forms of tumor—varicocele, the different forms of hydrocele, enlarged 
inguinal or femoral nodes, aneurism, psoas abscess, undescended testis, and 
malignant disease. 
A varicocele gives no distinct impulse on coughing, it disappears in the recum- 
bent position and reappears in the erect, even when firm pressure is made over the 
inguinal ring ; palpated, it suggests a bunch of earth-worms. A congenital hydro- 
cele is translucent, gives no impulse on coughing, disappears with the recumbent 
position, reappears slowly in the erect, and is dull on percussion. The coexistence 
of hydrocele and hernia renders diagnosis difficult. An encysted hydrocele of the 
cord is persistent, fluctuating, does not disappear in the recumbent position, and 
gives no impulse on coughing. An hcematocele is caused by traumatism; is dull, 
opaque, and gives no impulse on coughing. 
Femoral Hernia.—This variety of hernia is next in frequency to 
the inguinal, occurring in 10 per cent, of all cases. It is found most 
commonly in women. Femoral hernia is always acquired and. is very 
liable to strangulation. The protrusion takes place through the femoral 
ring into the femoral canal, a passage about half an inch in length 
between the iliac, crural, and pectineal portions of the fascia lata. The 
hernia usually lies to the inner side of the femoral vein. 
Femoral herniae emerge through the saphenous opening of the fascia lata, and 
are directed upward and outward upon the abdomen. The point of constriction 
in this variety of hernia is at Gimbernat’s ligament. 
For the diagnosis of femoral hernia, see Differential Diagnosis under Inguinal 
Hernia; for the treatment of femoral hernia, see Treatment of Hernia. 
Umbilical Hernia.—1, Congenital; 2, Infantile; 3, Acquired. 
1. Congenital umbilical hernia is due to defective closure of the 416 
HERNIA, 
omphalo-mesenteric duct. The sac is translucent; through it the hernial 
contents can often be seen. The hernia consists usually of some portion 
of the intestine, but may be made up of the whole or of part of any 
of the abdominal viscera. (See Fig. 186, case of congenital umbilical 
hernia of liver.) 
Fig. 186. 
Hernia of liver through congenital opening in the umbilicus (Dr. J. C. Warren, Massachu- 
setts General Hospital). 
The treatment of this form of umbilical hernia may be palliative 
or operative. Palliative treatment consists in the application of suit- 
able pads; operative, in removal of the sac, reduction of its contents, 
and closure of the ring. It is generally necessary to operate within a 
few hours after birth. 
2. Infantile umbilical hernia is the commonest variety of umbilical 
hernia. It generally appears between the second and sixth months of 
infancy. It is due to the stretching of the fibrous tissues of the umbil- 
icus in the straining caused by coughing, crying, constipation, phimosis, 
etc. The tumor is rarely larger than the tip of the finger. Its contents 
are almost invariably small intestine. The prognosis in this variety is 
good ; strangulation never occurs. In the majority of cases spontaneous 
cure results. The treatment consists in the use of small, hard pads, 
carefully adjusted, and in the removal of the usual causes of strain. 
Operation is seldom required. 
3. Acquired umbilical hernia occurs most frequently in women 
advanced in years. Pregnancy, ascites, abdominal tumors, excessive 
development of adipose tissue—in fact, all conditions of excessive and 
long-continued distention—are exciting causes. The hernial sac often 
contains only omentum, although it may contain both omentum and 
intestine. Strangulation of the intestinal portion of an umbilical hernia 
is common. An omental umbilical hernia generally becomes incarce- 
rated, and constantly tends to increase in volume from hypertrophy of 
fat-tissue. This form of hernia is associated with severe gastro-intestinal 
symptoms—indigestion, nausea, pain, constipation, etc., caused by trac- 
tion of the omentum upon the colon and the stomach. (For treatment 
of umbilical hernia see Treatment of Hernia.) 
Ventral Hernia.—Epigastric hernia, a lesion of rare occurrence, VARIOUS FORMS OF HERNIA. 
417 
consists in a protrusion usually of omentum in the linea alba between 
the ensiform cartilage and the umbilicus. It has the same predisposing 
causes as other hernia. It occurs, usually, in stout women. Epigastric 
hernia is generally slow in its development, and in its early stages pre- 
sents a tumor too small to be easily perceptible. When large enough 
to be readily felt, it presents the characteristics of an omental umbilical 
hernia. The omentum, fixed in its abnormal position, drags upon the 
colon and stomach, causing discomfort and pain. Gastric and intestinal 
disorders and nervous phenomena often ensue. In the absence of an 
external tumor this form of hernia can be only suspected. 
Hernia following- Laparotomy and other Wounds.— Ventral hernia 
may take place through any portion of the abdominal parietes, though 
its usual situation is in the linea alba. Ilernite through the scar of 
laparotomy and other abdominal wounds are the commonest forms. 
Predisposing causes of this form of hernia are— 
1. Sepsis in sutured abdominal wounds; 
2. Stretching of cicatrices of open abdominal wounds; 
3. Insufficient time in the recumbent position; 
4. Any condition involving undue and persistent strain, especially 
upon broad granulation-cicatrices. 
Strangulation in this form of hernia is a rare occurrence. 
Hernia as the Result of Cong-enital Failure of Development.— 
Ventral hernia as the result of congenital defects in the abdominal wall 
may appear in any portion of the parietes, but is especially liable to 
occur in the line of muscular aponeuroses. 
Diaphragmatic Hernia : 
1. Congenital, through a defect in the diaphragm ; 
2. Acquired, through one of the natural openings in the dia- 
phragm or through wounds or rupture of the diaphragm. 
The hernial protrusion may vary in size from a small portion of intes- 
tine to one-half the contents of the abdomen. It is six times more com- 
mon on the left side than on the right. In the acquired form symptoms 
of intestinal obstruction, after a wound of the diaphragm, indicate dia- 
phragmatic hernia. In the congenital variety the heart is displaced to 
the right, and the lower part of the thorax is usually dull on percus- 
sion. The condition is frequently confused with pyo-pneumothorax. Trau- 
matic cases have recovered after operation. 
Gluteal or Ischiatic Hernia.—This form of hernia is very unusual. 
The hernia may take place through either the greater or the lesser 
sacro-sciatic foramen (Fig. 187). 
Obturator hernia, usually occurring in stout women advanced in 
years, consists of a hernial protrusion along the vessels through the 
obturator foramen. The contents of the hernial sac may be either 
intestine or omentum. The diagnosis is impossible without the presence 
of an external tumor. 
Perineal Hernia.—This rare and obscure form of hernia originates 
in Douglas’s fossa, behind the bladder or uterus, on either side of the 
median line. The protruding viscus forces its way between the fibres 
of the levator ani muscle, and appears externally somewhere between 
the labium and the anus. 
Lumbar Hernia.—This variety is very unusual, and consists in a 418 
HERNIA 
protrusion of abdominal contents, generally intestine, through the lum- 
bar fascia, along the outer border of the quadratus lumborum muscle 
into the triangle of Petit. It is usually of small dimensions and can be 
Fig. 187. 
easily reduced. It has been operated upon by mistake for fatty tumor 
and for cold abscess. 
Sacro-rectal hernia is of great rarity, and is due to failure in ossifi- 
cation of the sacral bones. 
Retroperitoneal Hernia.—This is a form of hernia into an internal 
peritoneal pouch. It usually occurs in the duodeno-jejunalis fossa. It 
may also take place in the region of the caecum or the sigmoid flexure. 
(See Internal Strangulations.) 
Hernia through the foramen of Winslow may occur, though very 
rarely. 
The symptoms, diagnosis, and treatment of strangulated retro- 
peritoneal herniae do not differ from those of acute intestinal obstruc- 
tion. When neither incarceration nor strangulation occurs the condi- 
tion may never be even suspected. 
Properitoneal Hernia.—This unusual variety of hernia may be a 
Ischiatic hernia (original). VARIOUS FORMS OF HERNIA. 
419 
complication of inguinal, femoral, or umbilical hernia. There must be 
two sacs with a common opening into the peritoneal cavity, the 
inner sac lying in the connective-tissue space in front of the peritoneum 
and behind the muscular layers of the abdominal wall, the outer sac 
occupying the position of an inguinal, femoral, or umbilical hernia. 
The usual cause of this condition is a mechanical separation of the 
peritoneum during attempts to reduce by taxis an existing hernia. 
A possible cause may be some congenital irregularity in the descent of 
the testis. Properitoneal hernia should be suspected when, after appar- 
ent reduction of inguinal, femoral, or umbilical hernia, there is no relief 
of symptoms (Fig. 188). 
Fig. 188. 
Properitoneal hernia. This illustrates also incomplete reduction of hernia. 
Hernial Diverticula from the Bladder.—Portions of the urinary 
bladder have been found in inguinal and femoral hernise. It is a rarity, 
and occurs usually in old persons. Urinary symptoms are vague and 
inconstant, and the condition is seldom diagnosticated before operation. 
The extraperitoneal portion of the bladder is prolapsed in the great ma- 
jority of cases. This variety of hernia is sometimes called a cystocele. 
Treatment.—If, as is rarely the case, the bladder is recognized 
before it has been injured, it should be freed and reduced. If the 
bladder has been opened, it should be closed by sutures and replaced. 
In certain cases, owing to necrotic changes, a temporary urinary fistula 
is inevitable ; the wound must be left open and drained with gauze. A 
distinct adherent diverticulum may be dissected out. 
Hernia of the Vermiform Appendix.—The vermiform appendix 
not infrequently appears in the sac of an inguinal hernia, either alone 
or with other parts of the intestine. Under ordinary circumstances its 
presence cannot be diagnosticated. If incarcerated, an acute appendi- 
citis may develop, resulting in necrosis, gangrene, and abscess. 420 
HERNIA. 
Treatment of Hernia. 
Palliative Treatment of Hernia.—The palliative treatment 
of hernia consists in returning the protruded contents of the sac to the 
abdominal cavity and keeping them there. To restrain the abdominal 
contents, trusses and supporters are employed. Supporters are useful 
in large scrotal and umbilical hernise which have become irreducible or 
which cannot be retained in the abdominal cavity. 
Trusses are indicated in those cases in which restraint is practicable and com- 
plete. In all forms of hernia, and especially in those of early life, the use of 
trusses offers a reasonable expectation of cure. Trusses should, therefore, 
be faithfully used. The success of palliative treatment depends upon the 
closure and obliteration of the channel of escape. It is essential for the accom- 
plishment of this end that the contents of the hernial sac be kept in the abdomen 
and never be allowed to escape for a moment may, by permitting a sudden recur- 
rence, undo the work of months. The pressure of a truss doubtless aids greatly 
in the obliteration of the canal, if, indeed, it is not the chief factor. Trusses are 
necessary also in cases of reducible hernia, in which for some reason radical cure 
is contraindicated or refused. The proper truss should possess a steel spring of 
sufficient strength to retain the hernia; it should be elastic enough to follow the 
movements of the body and still remain in position ; it should fit closely to the 
body just below the iliac crest, leaving the abdomen and gluteal muscles free; it 
should possess a pad of suitable material and shape to be retained over the hernial 
ring at all times. Pads may be made of wood, rubber, or ivory, and may or may 
not be covered with leather. Persistent pain and annoyance after the first few 
days of use show that the truss is unsuitable. 
The employment of a truss, once begun, must be kept up continuously 
for a long period of time. Contraindications to the use of trusses are— 
1. Irreducible omentum; 
2. Irreducible, inflamed, and strangulated intestine; 
3. A hydrocele on the same side; 
4. Abnormal position of the testicle; 
5. The lack of requisite time and care, due to incompetency, 
ignorance, poverty, or occupation ; 
6. Properitoneal hernia. 
Non-operative measures for the treatment of irreducible hernia are 
posture, long-continued moderate pressure, and taxis, used separately or 
in combination, aided at times by the application of local heat or cold. 
By keeping the patient with the hips elevated, by applying the constant 
pressure of sand-bags over the hernial tumor, with gentle and persistent 
taxis, hernia of great dimensions can sometimes be successfully reduced. 
The patient may be kept for days with the foot of the bed raised and 
with sand-bags, gradually increased in weight, applied directly to the 
tumor. The treatment should be abandoned the moment it becomes 
painful. 
In obstructed hernia the chief efforts should be directed to the relief of consti- 
pation—by means of high enemata and mild laxatives, with gentle massage of the 
tumor. Persistent obstruction demands exploration and mechanical relief. 
Inflamed hernice should be treated by rest in bed and local applications of heat 
or cold. Efforts at reduction should be postponed until the subsidence of the 
local inflammation. 
Irreducible, obstructed, and inflamed hernia should be closely watched for symp- 
toms of strangulation. In doubtful cases the sac should be opened and a radical 
cure attempted. Considering the success which modern methods ensure, both as to 
immediate safety and permanent cure, palliative treatment, in the absence of TREATMENT OF HERNIA. 
421 
distinct contraindications, is justly deemed a greater risk, on the whole, than 
operation. 
Operative Treatment of Hernia.—Irreducible hernise, whether or 
not incarcerated or inflamed, should invariably be treated by open 
incision and radical cure. When for any reason operation is contrain- 
dicated or refused, reduction of the hernia by palliative methods should 
be attempted. 
Treatment of Strangulated Hernia.—The great mortality in stran- 
gulated hernia being due to delay (acute intestinal obstruction, shock, 
gangrene of bowel, general peritonitis) or to violent taxis (rupture of 
bowel, extravasation, general peritonitis), it is imperative, first, that the 
treatment, whether by taxis or by operation, be entered upon at the 
earliest possible moment; and secondly, that taxis should be employed 
for a brief period only. 
Treatment by tlie use of ice-bags, by posture, or by palliative measures other 
than taxis promises so little, and, when minutes are precious, adds so materially to 
the delay, that these methods are mentioned only to be condemned. 
Treatment by taxis is to be recommended in the very beginning of strangula- 
tion, for it often succeeds at that time. Moreover, the chief danger, rupture of 
the intestine, is unlikely to occur, even if the manipulations are forcible. In the 
later hours of a strangulation, when the bowel, swollen by congestion and oedema, 
is jammed through a tight ring into the sac, taxis is hopeless and worse than 
useless. 
When employed, taxis must be gentle: its good effects, if any, will be the result 
of persistent and moderate, rather than of brief and forcible, manipulations. By 
compressing the sac between the thumb and fingers of both hands toward the ring, 
at the same time manipulating the tumor in various ways, the tension of the sac 
may, by the reduction of the gaseous or fluid contents of the constricted intestine, 
be relieved. Such a reduction—small though it may be—promises complete relief. 
In the case of femoral or of inguinal hernia reduction by taxis is encouraged by 
flexion of the thighs. 
The dangers of taxis are as follows : 
1. Rupture or bruising of the intestine or sac; 
2. Tearing of adhesions ; 
3. Reduction en bloc; 
4. Fatal delay. 
If persistent gentle pressure be unavailing, herniotomy is demanded. 
In strangulated hernia the emergency to be met by operation is acute 
intestinal obstruction. This emergency may require merely simple division 
of the constricting ring; it may require intestinal resection or artificial 
anus. Measures for radical cure may be considered in non-septic cases 
after the satisfactory relief of the obstruction. 
The first step in herniotomy is exposure of the sac. In the usual 
forms of hernia—inguinal and femoral—the dissection should be made 
by layers until the sac is reached. The only layers recognizable, how- 
ever, are the skin, fat, and possibly the dartos. The sac is recognized 
usually by its color. To make sure, the sac, with a bit of intestine, may 
be pinched between the thumb and the fore linger, when the intestine 
will slip away with a characteristic sensation, leaving the sac alone 
between the fingers. A little practice will make the sensation so familiar 
that it cannot be mistaken. The sac is now opened without fear of 
cutting the enclosed bowel. 
In cutting down upon the sac in umbilical hernia the greatest care is necessary 
not to wound the intestine, for at times the gut is directly under the skin, and sepa- 422 
HERNIA. 
rated from it by the peritoneum only. In some instances the skin over the strangu- 
lated bowel is so thin that it takes the characteristic color of strangulated intestine. 
The sac is usually distended with fluid which is clear, bloody, purulent, or fecal 
according to the pathological condition of the affected gut. A cover-slip prepara- 
tion made at the time may determine the question of sepsis, as well as that of the 
advisability of drainage, radical cure, artificial anus, or resection. 
The constricted bowel will be slightly congested, darkly congested, 
here and there necrotic, or totally gangrenous. In the absence of 
immediate bacteriological examination it may be difficult in doubtful 
cases to determine the viability of the intestine. As a rule, a congested 
gut, even if dark red, is viable; a greenish one, necrotic. Macroscopic 
perforation, total necrosis, or fecal abscesses are conspicuous. The chief 
1 point in doubtful cases is the determination of bowel integrity. Inasmuch 
as an absolute demonstration is impossible in such cases, safety and con- 
servatism require that doubtful cases should be treated as if they were 
septic. 
The next step is division of the constricting ring. 
In femoral and in inguinal hernia the division of the ring should be made with 
reference to the position of arteries and veins: in inguinal, to that of the deep 
epigastric artery; in femoral, to that of the femoral vein. The operations of the 
past were described in great detail in reference to these points, because of the desire 
to make as small a cut as possible, and that blindly upon the finger. Though it is 
still desirable not to enlarge the rings by free dissection, the parts may be clearly 
demonstrated in doubtful cases, especially in inguinal hernia, in which by the best 
of modern radical operations extensive dissections are essential. 
Simple division may be made, however, upon the finger with a probe- 
pointed bistoury; in direct inguinal hernia the cut should be made 
upward and inward, to avoid the deep epigastric artery; in indirect, 
upward and outward; in femoral hernia, upward and inward, to avoid 
the femoral vein. In the last form of hernia, however, an abnormal 
obturator (derived from the epigastric) artery may be found impossible 
of avoidance. 
After division of the rings the bowel should be drawn out of the 
wound until sound portions are visible, care being taken in septic cases 
to protect the peritoneal cavity from infection. 
The question of sepsis having now been determined by renewed 
examinations, especially for signs of returning circulation, minute per- 
forations, etc., there remains for the completion of the operation either 
(1) replacement of sac-contents in the abdomen, (2) intestinal resection, 
or (3) the formation of an artificial anus. After return of the gut in 
aseptic cases the operation for radical cure should be performed. (See 
Radical Cure of Hernia.) 
The method selected will vary with the size of the rings, the extent of 
the incision, etc. Resection of the intestine when its integrity is com- 
promised should be performed only when the patient’s strength permits. 
When shock is profound, and when exhaustion is marked it is better to limit 
the operation to relief of the constriction and formation of an artificial anus. 
In performing resection and suture especial care must be taken to pre- 
vent a general infection, inasmuch as the field of operation is extremely 
septic. (See Intestinal Resection and Suture.) In favorable cases the 
prognosis is encouraging, there being probably 50 per cent, of recoveries. 
The formation of an artificial anus is attended by unusual difficulties in THE RADICAL CURE OF HERNIA. 
423 
gangrenous hernia, because both proximal and distal openings must be 
fastened into a septic wound. The bowel ends must be securely united 
to the skin, and drainage must also be used to prevent a general 
infection. Moreover, this operation must be followed by secondary 
resection and suture. The formation of an artificial anus, therefore, is 
not very much safer or easier than complete resection and suture, though 
it may be more rapidly performed. In case of extreme need the necrotic 
loop may be rapidly excised and the bowel ends stitched hastily to the 
skin ; or the gangrenous loop may be simply incised after division of 
the ring, the coil being held in its position by adhesions. Resection, 
on the other hand, demands a careful suturing of the approximated 
bowel ends, an operation which requires at least half an hour even in 
the hands of the most skilful. 
The mortality of artificial-anus formation is high, not from the operation, but 
from the profound systemic depression which indicates that procedure. General 
anaesthesia adds a serious danger when the patient is collapsed and vomiting. 
Many deaths on the table during herniotomies are due to strangulation from gas- 
tric regurgitation. If general anaesthesia is used it must be sparingly administered 
and carefully watched. (See Peritonitis, Intestinal Resection, etc.) 
Intestinal obstruction persisting after herniotomy should suggest a 
reduction en bloc (Fig. 188) or a twist in the intestinal loop. The 
former accident, occurring not infrequently after taxis as well as herni- 
otomy, is caused by a forcible replacement of the gut, constricting ring 
and all, inside the abdominal cavity. Reduction en bloc is not likely 
to occur after complete division of the ring : it may take place when the 
incision is made blindly with the probe-pointed bistoury deep upon the 
finger. Careful digital exploration will demonstrate whether or not the 
relief of the constricting ring has been complete. 
Obstruction from a twist is extremely rare. It cannot be prevented, 
and can be demonstrated only by secondary exploration. Acute obstruc- 
tion may persist as the result of faulty adhesions. 
Necrosis of the intestinal mucosa with subsequent contraction and 
stricture may cause, ultimately, a chronic obstruction. Stenosis at the 
line of suture rarely follows enterorrhaphy. (See Intestinal Resection.) 
Pseudo-ileus, due to paresis of the muscular coats, is not infrequently 
observed. 
The Radical Cure of Hernia. 
The present methods for the radical cure of hernia have entirely 
supplanted the earlier operations, which were clumsy, ineffectual, and 
dangerous. 
The principal early methods were— 
1. Injection of irritants in the neighborhood of the pillars and rings; 
2. Irritation from the pressure of plugs ; 
3. Subcutaneous wiring and suture. 
The extensive experience of the past few years with the cicatrices resulting 
from abdominal wounds has shown that scar-tissue under persistent pressure 
stretches and gives way, and that a large percentage of ventral hernise results. 
Hence the inefficiency of the granulation method (McBurney’s), a method in which 
it was expected that after excision of the. sac high up, and suture of the skin to 
the muscular layers, healing from the bottom, induced by packing the wound 
with gauze, would ensure a cicatricial barrier that would not give way. 
Careful observations after long periods of time have proved that these operations 424 
HERNIA. 
are followed by a large percentage of relapses; and though perhaps sufficient time 
has not elapsed to ascertain the ultimate results in the later operations, there 
seems no doubt that the improvements in the mechanical operative technique of 
the radical operations of the present day will lead to better results than were 
attained in the operations of the past. 
The present methods of radical cure are all carried out after thor- 
ough exposure of the field by careful dissection. The sac is either 
isolated and removed or used as a wad to fill the ring (Macewen’s). 
The pillars of the ring are sutured, or the spermatic cord, after removal 
of the sac, is transplanted to a new and artificial ring after closure of 
the inguinal canal and the external ring. 
The best methods of operative cure depend upon perfect asepsis: without it all 
methods fail. They require also extensive dissections of the whole field, with 
exposure of the inguinal canal and rings, with isolation and removal of the sac 
well above the constricting ring, and with as perfect obliteration as possible of a 
protruding peritoneal pouch. They require, finally, restoration of the divided lay- 
ers of the abdominal wall with obliteration of the former canal by buried sutures, 
and with provision of an artificial channel for the spermatic cord. 
At the present time two methods for the radical cure of inguinal 
hernia are to be preferred, that of Bassini and that of Halsted. 
Bassini’s Operation.1—“1. The external incision begins at a point 
nearly or quite on a level with the anterior superior spine, continues 
obliquely down parallel to and about half an inch internal to Poupart’s 
ligament, and ends at the centre of the external ring. 
2. The incision is rapidly carried down until the aponeurosis of the 
external oblique is freely exposed for a distance of two and a half to 
three inches; a director is then passed through the external ring just 
beneath the aponeurosis, and the aponeurosis is divided well above— 
i. e. a half to one inch above the internal ring. 
3. The cut edges of the aponeurosis are held up with forceps and 
dissected free from the underlying muscles as far as the edge of the 
rectus, internally and externally, until the shelving portion of Poupart’s 
ligament lias been clearly exposed. 
4. The sac and cord are then isolated en masse, and this is best 
accomplished with the lingers and blunt-pointed curved scissors. If 
the peritoneal layer of the sac is first reached, the dissection is easy, 
rapid, and bloodless. 
5. The cord and its vessels are now separated from the sac, and this, 
too, is best done with the fingers. The separation is carried high up 
within the internal ring, and the sac is opened and its contents ex- 
amined. If adhesions are present, they are separated; omentum, if 
thickened, is excised, and the contents are reduced into the abdominal 
cavity. The sac is then ligated or sutured above the internal ring, 
where it merges into the general peritoneal cavity. 
6. The cord is held up and the edges of the aponeurosis rolled back, 
while from three to five buried sutures are introduced beneath the cord. 
These are best introduced from within outward, and should include the 
internal oblique and transversalis muscles, the transversalis fascia (and 
sometimes the edge of the rectus) on the inner side, and the deep shelv- 
1 “Ueber die Behandlung des Leistenbruches,” von Ed. Bassini, Archiv f. klin Chir., 
Bd. 40, 429, 1890, quoted by Bull and Coley in the article on Hernia in System of Sur- 
gei'y by F. S. Dennis, vol. iv. p. 184. THE RADICAL CURE OF HERNIA. 
425 
ing portion of Poupart’s ligament on the outer side. The lowermost 
suture should embrace the conjoined tendon. 
7. The cord is now replaced, and the cut aponeurosis is closed over 
it by means of a continuous suture extending as near the pubis as pos- 
sible without causing undue constriction of the cord. 
8. Closing the skin-wound with interrupted sutures, without drainage, 
completes the operation (Figs. 189,190, 191). 
Fig. 189. 
Bassini’s method of operation for inguinal hernia: A, A, A, subcutaneous fatty tissue; B, upper 
portion of the divided aponeurosis dissected from underlying structure; C, under portion of 
aponeurosis of external oblique; E, cord; F, 1, internal oblique muscle ; 2, transversalis ; 3, 
fascia of Cooper (Bull and Coley, foe. cit.). 
Bassini at the time he published his paper (1890) had operated upon 
262 cases of inguinal hernia, with but 1 death and but 7 relapses. All 
but 4 of his cases had been traced (Bull and Coley). 
Halsted’s method consists in the following steps : 
1. An oblique incision is made by which the external abdominal ring 
is thoroughly exposed. 
2. An incision 3 cm. long is made through the aponeurosis of the 
external oblique, and through the internal oblique to the internal abdomi- 
nal ring. The external oblique is incised parallel with its fibres; the 
internal oblique is divided at right angles to its fibres (the line of incis- 
ion deviating from, not parallel to, the previous incisions through skin 
and aponeurosis of external oblique). The incision in the external 
oblique should be parallel with its fibres. 
3. The prolongation of the fascia transversalis (tunica vaginalis 426 
HERNIA. 
propria funiculi spermatici), which includes the cord, is first split with 
a knife and then torn. 
4. The larger bundle of veins is separated from the vas deferens 
with as little disturbance to the vas deferens as possible. The larger 
bundle of veins is excised from the external to the internal ring; the 
smaller veins accompanying the vas deferens are left undisturbed. In 
children the veins should not be excised. It is usually advisable to 
Fig. 190. 
Bassini's method of operation for inguinal hernia: the end of the third step of the operation. 
The cord has been transplanted and the museulo-aponcurotic tissues on the inner side have 
been sutured to Poupart’s ligament (D) on the outer side (interrupted sutures are usually em- 
ployed) (Bull and Coley). 
excise the veins in adults, unless they contribute but little to the size 
of the cord. 
5. The sac is isolated, opened, transfixed, and tied with one or more 
sutures, cut off, and the stump dropped into the abdomen. 
6. The vas deferens should now be transplanted to the outer angle 
of the muscle wound ; the muscle flaps are brought down with forceps so 
as to enable the operator to include them in all the sutures, except one 
or two. The vas deferens should be snugly embraced between, but not 
constricted by, the two outermost stitches (Figs. 192, 193). 
The muscular and tendinous layers of the ring and abdominal wall 
are carefully sutured, layer by layer, with Halsted’s quilted suture ; 
the material used may be silk, animal tissue, or silver wire. The wound 
is closed without drainage. The stages of the operation are shown by 
the diagrams. THE RADICAL CURE OF HERNIA. 
427 
Fig.191. 
Bassini’s method of operation for inguinal hernia: fourth step. Suture of the divided apo- 
neurosis over the cord with a continuous suture (Bull and Coley). 
The results by Halsted’s method, up to April 1, 1896, are extremely encourag- 
ing. Of 180 cases, 110 have been under observation since the operation, 20 have 
Fig. 192. 
Halsted’s operation for inguinal hernia : first step (Bull and Coley). 
been lost sight of. There has not been a single real recurrence. With the excep- 
tion of 5 cases all are perfectly healed. There is not the slightest protrusion or 
unnatural impulse on coughing. Five cases cannot be called absolutely perfect 428 
HERNIA. 
cures, though in but 1 of the 5 cases was there a complete, undoubted recurrence 
from stretching of the scar. 
The use of silver wire instead of silk has been followed by more perfect 
recoveries than were seen in the earlier cases, there having been but one case of 
suppuration in two and a half years.1 
Halsted’s operation for inguinal hernia: second step (Bull and Coley). 
Recurrence after Operation for Radical Cure of Inguinal Her- 
nia.—Under modern methods recurrence after operation for radical 
cure has become infrequent, though it remains to be seen whether the 
results will still be as good after the lapse of years. 
Fig. 194. 
Halsted’s operation for inguinal hernia: third step. 
Predisposing causes of recurrence are—the giving way of stitches, 
the use of drainage, septic infection and healing by granulation, 
advanced age of the patient, the large size of the hernia, relaxation of 
scar, fatty abdominal wall, etc. 
1 Personal communication. 429 
THE RADICAL CURE OF HERNIA. 
Treatment for the Cure of Inguinal Hernia in the Female.—This 
consists in excision of the round ligament and hernial sac, and obliteration 
Fig. 195. 
of the canal by the same method of buried suture employed in the cure 
of inguinal hernia in the male. Recurrence is extremely infrequent. 
The Radical Cure of Femoral Hernia.—Bassini’s method is the 
Femoral hernia, radical cure by Bassini’s method: sutures in position. 
Fig. 196. 
Bassini’s method of radial cure of femoral hernia: suture tied. 
best. It consists in an incision just below and parallel to Poupart’s 
ligament, with its centre over the hernial tumor. The sac should be 
exposed, freed as high up as possible, opened, its contents examined and 
reduced into the abdominal cavity. The obliteration of the pouch should 430 
HERNIA. 
be attempted by high ligation and removal of the sac. The structures 
of the femoral canal, the falciform, crural, and pectineal fasciae, Pou- 
part’s and Gimbernat’s ligaments, must be carefully identified and 
approximated by buried sutures. The femoral canal may be closed by 
four or five sutures uniting the falciform edge of the fascia lata to the 
pectineal fascia. The femoral ring should be closed by three sutures, 
uniting Poupart’s ligament and the pectineal fascia in a line from the 
pubic spine to the pectineal eminence. The external wound should be 
closed without drainage. (For stages of operation for Radical Cure of 
Femoral Hernia, see Figs. 195, 196.) 
Treatment of Umbieicae Hernia.—The treatment of umbilical 
hernia in adults should be operative in almost all cases, because of the 
extreme difficulty of retaining the hernia within the abdominal cavity 
by any form of truss, and because of the danger of inducing inflam- 
matory changes by any form of mechanical treatment. The operation 
for radical cure consists in making a long incision around the tumor, 
including the umbilicus and a large part of the hernial covering. This 
incision should open the sheath of the rectus on either side. After the 
hernial sac has been opened its contents should be carefully examined 
for coils of intestine, which should be reduced into the abdominal cavity. 
Prolapsed omentum should be ligated and removed. Adherent and 
necrotic portions of the intestine should be treated as in any form of 
hernia. After the sac has been emptied of its contents, it should be 
dissected free from surrounding structures, all redundant portions 
removed, and the edges carefully sutured together. The muscular 
bellies of the recti should then be approximated by buried sutures, and 
the external and superficial structures of the wound closed without 
drainage. 
Ventral heniice may be operated upon for radical cure in the same 
manner. CHAPTER X. 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
Charles B. Kelsey, M. D. 
Before taking up the different affections of the rectum in detail a 
few words of a general character may be useful. 
The diseases of the rectum itself-—that is, those which are confined to 
the lower six inches of the intestine, or even to the rectum and sigmoid 
flexure—are easily enumerated. The diseases outside of the rectum 
itself which by pressure or nervous influence or propinquity will cause 
symptoms in the rectum, particularly painful or irregular defecation, are 
many. The two classes of cases must be equally understood before much 
success can be hoped for in the treatment of the rectum alone; for if 
there is any disease of any organ in the male or female pelvis which 
may not cause pain in the rectum and simulate some disease of the rec- 
tum itself, the writer fails for the moment to recall it. In many such 
cases the rectum will he found normal on examination; in others some 
palpable affection, as hemorrhoids, may be found, but treatment of these 
will entirely fail to give relief. 
Congenital Defects. 
Congenital defects consist, for the most part, of forms of more or 
Fig. 197. 
Congenital absence of anus, rectum terminating by a cul-de-sac (Potherat) 
431 432 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
less complete absence of the rectum or imperforate anus, which are better 
illustrated in the accompanying illustrations than described by words. 
Fig. 198. 
Same as Fig. 197. 
They all cause symptoms of obstruction of the bowels unless speedily 
recognized and relieved. 
Fig. 199. 
Congenital defect of rectum: ano-rectal obliteration (Potherat). 
When a new-born infant has failed to soil its diaper within twenty- 
four, or at most thirty-six, hours, a careful examination with the little 
finger or with a catheter should be instituted. Should this reveal the 
condition or should the urine be stained with fecal matter, immediate 
anaesthesia and operation—depending upon the local condition—are 
imperative. If after careful exploration with knife, finger-tip, and HEMORRHOIDS. 
433 
sound no trace of rectum be discovered, it will be better to do a colos- 
tomy (see below) than trust to further search at the pelvic outlet. 
Fig. 200. 
Same, rectum opening into bladder (Potherat). 
Fig. 201. 
Rectum terminating by continuation into the penis (Potherat). 
These conditions are always serious, too often fatal. They are rare, 
but urgent when present. 
The most common of all the diseases of the rectum is hemorrhoids, 
and there is perhaps no better classification of them than the old one of 
external and internal. By an external hemorrhoid is meant one which 
Hemorrhoids. 434 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
arises from the margin of the anus outside the external sphincter muscle. 
It differs absolutely from the internal variety in the fact that it is 
always composed either of skin and hypertrophied connective tissue, 
forming a mere cutaneous tag, or else is composed of a clot of blood 
extravasated from a small cutaneous vein. Internal hemorrhoids, on 
the contrary, although composed in great measure of enlarged veins, 
have a very free arterial supply, and are a mere collection of enlarged 
blood-vessels bound together by hypertrophied connective tissue and 
covered by the natural mucous membrane of the rectum. An internal 
hemorrhoid is, moreover, an affection of the middle hemorrhoidal veins 
and arteries, which are parts of the visceral system and not of the 
cutaneous blood-supply. 
Internal hemorrhoids may also, with advantage, be divided into two 
classes. In one there is the large prolapsing tumor, generally recog- 
nized as a pile by the profession and laity alike. In the other we find 
theflat, strawberry-like surface, raised only slightly above the surround- 
ing healthy mucous membrane, closely resembling nsevus in anatomical 
structure, and causing'no symptoms except those which come from the 
frequent and often excessive loss of blood. 
Without going at all into the pathology or symptomatology of this 
very common and simple affection, which lack of space forbids, we will 
at once consider what is of most practical interest—the treatment. 
The treatment of internal hemorrhoids may be either palliative or 
radical. 
For palliative measures we have careful attention to diet to secure 
regularity in defecation, attention to the general health, and the free 
use of cold applications to the mass when protruding after stool. For 
bleeding we have the dry subsulphate of iron, which may be lightly 
sprinkled over the tumors when extruded, or used in a suppository, one 
grain at a time. This is apt to cause considerable smarting pain. 
Small bleeding tumors may be completely cured by touching them 
two or three times with strong nitric acid ; and a very severe hemor- 
rhage may sometimes be stopped for a long time by this simple method, 
even where there is no hope of a radical cure. But in large, old pro- 
lapsing tumors the free application of acid to the surface will only cause 
additional pain. 
The injection of carbolic acid in some medium, such as glycerin and 
water, is also a palliative measure which has had great notoriety. It is 
attended by a chain of accidents which make its use very uncertain, 
and in many cases unsatisfactory. There are great pain, swelling, the 
formation of pus, and sloughing. 
In any large number of trials some of these results are sure to follow, to the 
disgust of both patient and physician, while the relief obtained by the method, 
even in the cases which escape these accidents, is but short. 
The radical or operative treatment of hemorrhoids consists in their 
removal in any one of many ways, all of which involves the use of an 
anaesthetic and more or less confinement to bed, as after any surgical 
operation. Of these only a few will be considered. 
In small tumors, where there is little to tie or clamp, and perhaps 
where there is no protrusion at stool, and yet free bleeding and all the 
other symptoms of hemorrhoids, an exceedingly effective means of cure 435 
HEMORRHOIDS. 
is punctate cauterization. The sphincters should be well dilated, a Sims 
rectal speculum introduced, and the tip of the Paquelin cautery at a 
dull red heat inserted into the substance of the tumor. 
The writer often does this to the small varicosities which will sometimes 
remain after an operation with the clamp or ligature. It is often the case that 
after several very large masses have been tied or clamped oft' there will still be 
one or perhaps two small spots which seem hardly big enough to call for another 
application of the clamp, and yet which the operator does not like to leave. A 
single touch with the cautery solves the difficulty; and it is to small tumors of 
this size that the method is most adapted, although the French have advocated it 
in all cases, large or small, requiring operation; and it is effective. 
Whitehead’s operation consists in removing the mucous membrane 
from the lower inch of the rectum in a cylinder, and with it the hem- 
orrhoids. There is no essential difference between it and the so-called 
“ American operation except that in the former the first incision is 
made in the line of junction of the skin and mucous membrane, and the 
dissection carried upward, while in the latter the first incision is made 
inside the rectum above the hemorrhoids, and the dissection carried 
downward. 
The objections to it are—the time necessary to perform it; the fact that no 
such elaborate operation is ever necessary to cure any case of hemorrhoids; and 
the liability to two accidents—first, the production of a stricture from failure to 
get union, and, second, the eversion of the mucous membrane caused by pulling it 
down and attaching it to the skin. Both of these results are now sufficiently fre- 
quent, and the number of secondary operations necessary to cure patients of the 
effects of the “American” operation is increasing. 
Between Allingham’s operation by ligature and Smith’s operation by 
clamp and cautery there may not be much to choose. Both are safe 
and both are radical, and either is quickly performed without profound 
anaesthesia or loss of blood. And yet for many years the writer has 
practised the latter in preference to the former, because in his hands it 
causes less pain, shorter convalescence, and less reflex vesical disturb- 
ance. This is explained by the fact that a ligature around the pedicle 
of a pile often includes in its grasp a nerve as well as an artery, and 
hence causes pain until it comes away. 
The clamp-and-cautery operation is done as follows: The patient is 
etherized and placed in the lithotomy position. The sphincter is 
thoroughly stretched without rupturing the muscle. Time should be 
given to this, and when the stretching is completed the anus should be 
patulous and without contractile power. Such paralysis will last two 
or three days only. 
After the stretching, the hemorrhoids, if of any size, will protrude, 
and the largest is seized with volsellum forceps and pulled gently still 
farther out from the anus. Its attachment is then cut through on the 
cutaneous margin with scissors. This cutting is done where the skin 
becomes continuous with the mucous membrane, and is intended simply 
to avoid including skin in the grasp of the clamp. Where the hemor- 
rhoid does not rest upon the muco-cutaneous junction, and the clamp 
can be applied to its base without including any skin, no cutting 
around the pedicle or base is necessary. 
In the incision thus made the clamp is applied, care being taken to 
include all that remains of the stump in its grasp, so that when the 436 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
pile is cut away none of its blood-vessels shall be outside the grasp of 
the instrument. The blades of the clamp should lie along the axis of 
the gut, and the stump when released from the grasp of the clamp 
should be in the line of the radiating folds of the anus, and not across 
them. 
No force is necessary in using the clamp. It is not a crushing machine, to be 
screwed down as tightly as possible. In most cases it would answer its purpose 
as well without the screw attachment, and in those most recently manufactured 
this is left off. It is merely a temporary haemostatic forceps to hold the stump after 
the pile has been cut off till the cautery can be applied to the cut surface. The 
only advantage of the screw attachment is that sometimes the cautery may not be 
ready, or the operator may have to attend to the anaesthetic, or maybe interrupted 
for a moment, when, with a turn of the screw, the clamp may be left in position 
for any length of time. 
Having grasped lightly the pedicle in the clamp, the pile is cut away 
at a sufficient distance from the damp to leave a good thick stump for cau- 
terizing. This is the important point in the whole operation. If the 
pile is shaved off close down to the clamp, there will be no room to cau- 
terize the cut vessels and firmly close their mouths, and the moment the 
clamp is relaxed they will bleed. There should be stump enough left so 
that the cautery at a dull red heat can be passed over its cut surface again 
and again till it is thoroughly charred, and a good thick eschar remains. 
The clamp is then gently relaxed, and if any vessel spouts, it can be 
closed and the cautery again used on that point; but if the eschar 
remains dry, it is allowed to slip from the grasp of the clamp and is 
gently pushed up into the rectum. 
Even in the cases of most extensive disease there will seldom be 
more than three large individual hemorrhoids, springing from different 
points in the circumference of the anus, and lienee more than three 
applications of the clamp are seldom necessary. When one mass has 
been removed, a little care should be exercised in removing the second 
and third, so that a distinct strip of mucous membrane may be left 
between the eschars, otherwise too much contraction may follow cicatri- 
zation. Half an inch of membrane at three different points in the cir- 
cumference will be found amply sufficient. If any small varicosity be 
found in these intervening spaces, puncture with the cautery as described 
will always be efficient to prevent their future development. 
After the operation there will always be some bleeding from the scissor-cuts 
made in the skin for isolating the pedicles; this is stopped by pressure of a pad 
and T-bandage. There should never be any hemorrhage from the eschars or from 
the cavity of the rectum. After a few hours the pad and bandage may be replaced 
by a hot poultice. The patient is allowed to stand and pass water; no restriction 
is made as to diet; his bowels are moved by a laxative forty-eight hours after ope- 
ration, and kept open every day or second day afterward. Straining and pain in 
defecation are best relieved by an enema of lukewarm water when the laxative is 
about to have its natural effect. Patients usually sit up on the second or third 
day, and leave their rooms by the end of a week, although complete healing can- 
not be expected in less than three weeks. 
After years of experience with this operation the writer can only say 
he has never had an accident, never had to use a catheter, seldom had to 
give morphine, and confidently expects a rapid and uneventful recovery 
in every case. But accidents have occurred, though the fault has gen- 
erally been with the operator and not the method. Only recently has POLYPI.—PROLAPSE AND INVAGINATION. 
437 
it happened to me to have a distinct case of secondary hemorrhage on 
the third day after this operation; but, as this is the only one I have 
ever seen, and as I happen to know of several after the ligature, my 
opinion of its value is unchanged. 
Rectal Polypi. 
Polypoid tumors are frequent in the rectum, especially in young 
children. They are of the myxomatous or 
adenomatous type or of mixed form, and vary 
much in size and number. Widespread poly- 
poid disease is represented in Fig. 202. Some- 
times they bleed easily. They are occasionally 
presented for inspection at or after stool, and 
may require replacement or reduction like cer- 
tain piles. They cause, for the most part, symp- 
toms of rectal malaise and tenesmus. Children 
who are frequently impelled to stool should be 
carefully examined—if need be under anaes- 
thesia—to discover polypi if present. These 
tumors are often pediculated, sometimes by 
long stems which are elongated by natural 
efforts at their expulsion. In such a case they 
may be twisted off. In other cases, when they 
are more sessile, their careful enucleation or 
destruction may be required. 
Fig. 202. 
Aggravated instances are known in which strain- 
ing efforts, long continued and often repeated, have 
produced invagination with all its disastrous conse- 
quences. 
There are two varieties of prolapsus, to be 
carefully distinguished from each other in 
practice. The first is composed of mucous 
membrane only (Fig. 203); the second, of all 
the coats of the bowel, and hence, when of suffi- 
cient extent, containing peritoneum. 
The first is a mere everting of the mucous 
membrane, rendered possible by the laxity of 
the submucous connective tissue. The second 
is an exaggeration of the first, in which, after the connective tissue has 
yielded to its utmost, the whole thickness of the rectum begins to pro- 
trude. It follows, of necessity, that after this protrusion has reached a 
certain point the peritoneal coat must also protrude through the anus. 
The first form of prolapse is seen frequently in children as a result 
of weakness, diarrhoea, or any irritation of the rectum which produces 
tenesmus. It is also seen in adults, generally as a result of weakening 
of the sphincters. It is a minor affection, and in all cases easily curable 
by surgical measures. The importance of distinguishing between it 
and the second variety at once becomes manifest when it is stated that 
Prolapse and Invagination. 
Multiple polypi of rectum 
(Potherat). 438 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
treatment adapted to it may easily result fatally when applied to the 
second. 
A serious and not very rare complication of the second form of pro- 
lapse arises from the fact that the pouch of peritoneum contained in it 
may he the sac of a hernia, and may contain coils of small intestine, an 
ovary, or the bladder. Usually the peritoneal pouch will be found on the 
Fig. 203. 
Partial prolapse of rectum (Potherat). 
front of the prolapse, but it may be both in front and behind, and, when 
intestine is contained in it, it may be reduced as in any other variety of 
hernia. 
The fact that in old cases of the second variety of prolapsus the gut 
is generally chronically inflamed, and hence weakened, and may easily 
tear or rupture, allowing the escape of small intestine through the rent 
and out of the anus, has given rise to many recorded cases of so-called 
rectal hernia—protrusion of small intestine through the anus—sometimes 
to the extent of many feet. It is doubtful whether the healthy rectum 
ever ruptures as a result of any ordinary violence, and the great majority 
of these cases are due to the existence of an old prolapsus containing 
coils of small intestine. 
There is one remarkable case on record, however, in a boy of thirteen, in 
whom, as a result of the fall upon him of a cart, a considerable part of the small 
intestine was forced out of the anus. The most remarkable part of the case is 
that, after the intestine had been replaced and had protruded again several times, 
and had become gangrenous, fifty-seven inches of it were cut off and the boy made 
a good recovery. This was in 1755, and shows what may happen without anti- 
sepsis. 
It is a mistake to suppose that the second form of prolapse is not 
met with in children, for it is only an exaggerated form of the first. 
It is distinguished from it, first, by its size, being from its nature of 
very considerable dimensions. The first form is not thick to the feel, 
the folds of mucous membrane radiate from the orifice to the circum- 
ference, and the opening is circular and patulous. In the second the 
orifice is slit-like, and is drawn backward by the attachment of the PROLAPSE AND INVAGINATION. 
439 
meso-rectum, or, in females, forward by the closer attachment to the 
vagina. The form of the tumor is conical; its walls are thick and firm ; 
and when pressed by the fingers the gurgling of gas in a contained loop 
of intestine may sometimes be felt. Such a tumor may also be resonant 
on percussion. 
The treatment of prolapse is both general and surgical. In 
children a polypus should always be looked for, and removed if found, 
as this is a very frequent cause of the condition. The same rule applies 
to calculus, phimosis, constipation, and pin-worms. The general health 
should be carefully attended to; the tumor when down should be 
washed with an astringent solution and replaced; and the child should 
be made to have its passages in bed, while the buttocks are held together 
by a nurse. 
Many cases of prolapse are due to the carelessness of nurses in putting small 
children upon the chamber and allowing them to remain there and strain. 
Should these measures fail, Van Buren’s operation with the cautery 
can always be relied upon to cure in prolapse consisting of mucous 
membrane alone. 
With the child under ether the pouting mucous membrane is seized 
with forceps and gently pulled out of the anus. Successive pairs of 
forceps are used on opposite sides of the anus till the whole amount of 
the protrusion is in sight. With the cautery at dull-red heat three, 
four, or even six stripes are drawn on the tumor, commencing at the 
apex and radiating toward the orifice. The cauterizations should 
extend only through the mucous layer, should be light at the apex, and 
should gradually increase in depth as they approach the sphincter. After 
a sufficient number of these linear cauterizations have been made at 
equal distances from each other on the circumference of the tumor, the 
whole mass is reduced. 
The after-treatment is of scarcely less importance than the cauteriza- 
tion. A firm graduated compress should be applied over the anus and 
secured by broad strips of adhesive plaster, which also draw the but- 
tocks firmly together. Opium and chalk or some other astringent 
should then be given by the mouth to keep the bowels from moving 
for a week or ten days, if possible. The first passage should be assisted 
by an enema of water, and should be had with the child in bed and a 
nurse pressing the buttocks together to prevent protrusion. For at least 
a fortnight this rule should be carried out. 
Occasionally it may be necessary to repeat the cauterization a second time, 
but this treatment will seldom fail in any case of prolapse of mucous membrane 
alone, where it is thoroughly carried out. 
In 'prolapse of the second variety this treatment will also often be 
found efficacious. It may also be made more radical by burning 
through the sphincter at two or three points. The idea of the radiating 
cauterizations through the mucous membrane is simply to bind it and 
the submucous connective tissue to the muscular coat by linear cicat- 
rices. In more extensive disease the orifice may also be reduced in size 
by burning through the sphincters, thus causing a slight degree of con- 
striction at the anus. 
But in many of the old and extensive cases of the second variety 440 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
this plan of treatment will fail, and we are then forced to more radical 
measures. 
One of the best of these is amputation of the entire tumor after the 
method of Mikulicz. The patient is placed in the lithotomy position. 
Two strong threads are passed through the extremity of the prolapse 
for fixation. A transverse incision is made through the anterior part 
of the prolapse till the serosa is exposed. The serosa of the outer layer 
is then stitched to the serosa of the returning portion, thus closing the 
peritoneal cavity. Just outside this row of sutures the anterior part of 
the returning cylinder is also cut across, and the two divided ends of the 
gut are then sutured with silk through the whole extent of the incision, 
the threads passing through all the coats and being left long for guides 
till the completion of the operation. Next the remaining portion of the 
periphery is cut across in the same way, the mesenteric vessels tied, and 
the suturing completed as in the anterior lip. All sutures are cut short 
and the stump of the prolapse reduced. 
The occurrence of a circular slough as a result of the strangulation 
of a prolapse is always a very serious complication. The tumor is gen- 
erally of the second variety; has become first irreducible, then strangu- 
lated, and at the apex, around the opening, there will be seen a black 
ring of dead mucous membrane and connective tissue of greater or less 
extent. 
The gravity of this condition consists in the fact that the circular 
slough may cause a severe stricture after cicatrization has occurred, and 
the longer the prolapse the higher up the bowel will the stricture be 
after it has been reduced. 
The treatment of this condition resolves itself into the ablation of 
the tumor by the method just described. 
The essential difference between prolapsus and invagination is that the 
former is a mere everting of the mucous membrane, and perhaps of the 
other layers, of the rectum, beginning always at the verge of the anus 
and gradually increasing in size as more and more of the gut protrudes 
from the body ; while the latter is a telescoping of one part of the gut into 
the part below, and may begin anywhere in the length of the tube. A 
prolapse necessarily protrudes from the anus; the invaginated portion 
of bowel may or may not do so, depending upon its length and location. 
When an invaginated portion of the bowel appears at the anus, it can always 
be distinguished from a prolapsus by the presence of a groove or sulcus between 
the enclosed and enclosing portion, or, in other words, between the intussusceptum 
and the intussuscipiens. The bottom of this sulcus, or what is technically known 
as the neck, may be reached by a finger in the rectum or by a long bougie, or it 
may be much higher up the bowel. It is evident that a cross-section through an 
intussusception will divide three distinct layers of gut in their entire thickness— 
the enclosing, the entering, and the returning portions. In the sulcus between the 
enclosing and the entering cylinders two mucous surfaces are in contact; in the 
sulcus between the entering and returning cylinders two serous surfaces are in 
contact. 
Of this condition there are many varieties and degrees. The most 
common (forming nearly one-half of all the cases) is the ileo-ccecal, or 
that in which the ileum and the caecum pass into the large intestine, 
carrying the ileo-caecal valve at the apex. This variety is apt also.to be 
the most extensive, the caecum passing sometimes the whole length of PROLAPSE AND INVAGINATION. 
441 
the colon and appearing with its valve and the appendix outside the 
anus. The next most frequent variety is that involving the small intest- 
ine ; and after these in freqnency come the cases affecting the colon, sig- 
moid fiexure, and rectum. \\ hen the large bowel is affected it is most often 
near its termination, the descending portion passing into the sigmoid 
flexure, the flexure into the rectum, or the upper part of the rectum into 
the lower. These latter forms are necessarily limited in length, for 
when once the invagination has been fairly formed, and after the enter- 
ing portion has been grasped, the increase in length is always at the 
expense of the sheath. 
The apex or point where the entering portion becomes the returning portion 
remains constantly the same, and the turning in is not done at this point, but at 
the neck. If, therefore, the neck be within the rectum, the intussusception must 
be limited by the length of the rectum remaining between the neck and the anus, 
and must be correspondingly short. 
An intussusception of the rectum or sigmoid flexure will also, as a rule, be 
straigliter and less curved than one of the bowel higher up, because of the absence 
of the mesentery in the tumor. As the involution goes on at the neck of the 
tumor the mesentery is drawm in between the two inner layers in the form of a 
cone with the base upward. The traction upon this causes a curve of the con- 
tained cylinder, the concavity of which is toward the attachment of the mesentery. 
In the small intestine this curve is very marked at times, and the mesocolon may 
cause the same appearance in cases involving the large bowel. The traction of the 
mesocolon may also cause other changes. The axis of the contained portion is not 
the same as that of the sheath, and the orifice is drawn into a slit-like shape and 
turned against the side of the sheath, so that it may be difficult to detect it with 
the finger. 
The obstruction and the strangulation of the contained portion may 
cause certain changes. The bowel above the implicated part may be 
simply distended and congested, it may he filled with faeces, or it may be 
ulcerated and perforated. The serous surfaces in apposition in the two 
contained portions are apt to become united by adhesions. When pres- 
ent and extensive these constitute the chief obstacle to reduction, whether 
spontaneous or the result of treatment. 
As a result of strangulation of the contained portion its walls may 
become much swollen by transudation of serum, the peritoneum con- 
gested, the mucous membrane infiltrated; blood is effused between the 
mucous surfaces of the outer and middle layers; and the whole con- 
tained portion becomes in this way irreducible. Should strangulation be 
sufficiently severe, gangrene may supervene, and this is Nature’s method 
of cure. It is more apt to take place in acute than chronic cases, and 
may involve the whole or part of the contained portion. As a result, 
many feet of bowel may slough off and be passed, either in small por- 
tions or in large cylinders. 
The treatment of intussusception consists, first, in gentle efforts 
at reduction. The mass must be replaced by a process exactly the 
reverse of the one by which it came down, the most dependent portion 
being first carried into the body, and the telescope unfolded in this way. 
This means failing, a reduction may be accomplished by laparotomy, or 
a gangrenous portion may be exsected, or an anastomosis established 
around the involved part. The operation of excision with circular enter- 
orrhaphy, as described under Prolapsus, may also be curative in old and 
chronic cases. 442 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
Chronic mvagination of the sigmoid flexure into the rectum, lasting 
for many years, is a condition quite frequently diagnosticated, but sel- 
dom seen. The writer has always believed, theoretically, that it might 
occur and might cause a peculiar train of symptoms, but has never seen 
an undoubted case till within the past year. Usually the cases turn out 
to be simple ones of very obstinate constipation attended with great 
mechanical difficulty in obtaining a movement of the bowels, and 
possibly with slight prolapsus and obstruction of the anus from crowd- 
ing down of the normally profuse folds of mucous membrane. A posi- 
tive diagnosis of invagination can only be made when the condition can 
actually be felt by digital examination, as the symptoms cannot be dis- 
tinguished from those of old cases of severe constipation. 
In the case referred to, however, the sulcus between the intussusceptum and 
intussuscipiens was well marked, soft, movable, and not to be mistaken for an 
organic stricture. Under ether the invaginated portion was drawn three inches 
out of the anus, while the ring could still be distinctly felt two inches within the 
sphincters. 
A combined operation was done. First, the anus was tightened by four appli- 
cations of the cautery to the sphincter, causing a slight amount of artificial 
stenosis. Second, the abdomen was opened by the usual incision for 
The sigmoid flexure was drawn upward into the wound to its utmost extent, and 
stitched as securely as possible by five silk sutures passed through one of the 
longitudinal bands and the abdominal wall, as in a ventral fixation of the uterus. 
For two weeks the patient was compelled to have his passages in the recumbent 
position. After that he was allowed to leave the hospital. Six months after the 
operation there had been no return of the disease. 
In one other case of prolapsus of very extensive proportions, due to locomotor 
ataxia, I have repeated this operation with equally good results. 
Abscess and Fistula. 
Abscesses around the rectum are best divided for clinical study 
into superficial and deep. By the former are meant those of the sub- 
cutaneous cellular tissue, which are generally of trifling importance, 
often break and heal spontaneously without the formation of fistulas, 
or, when resulting in fistula, leave one of the superficial and trivial 
variety easily curable by incision. 
The deep abscesses may be divided with advantage into those of the 
ischio-rectal fossa and those of the superior pelvi-rectal space, two ana- 
tomical regions whose relations are important. An abscess of the ischio- 
rectal fossa is below the levator ani muscle and outside of the pelvic 
fascia which covers that muscle, and separates the ischio-rectal region 
from the general pelvic cavity. An abscess of the superior pelvi-rectal 
space is above the levator muscle, within the true pelvis, and only closed 
off from the free pelvic and abdominal cavities by the peritoneum. 
An abscess of the ischio-rectal fossa shows itself with all the usual 
signs of an acute phlegmon, and can hardly be mistaken for anything 
else. 
It may begin with chill and considerable constitutional disturbance; there will 
be severe pain, and the skin will be hard, red, and oedematous over a considerable 
part of the buttock. The pus, if allowed to take its own course, finds its way into 
the rectum as well as to the skin, and deep fistulse are the result. It may*how- 
ever, tend upward in the perineum, being less confined in that direction, and the 
urethra may be so pressed upon as to cause retention of urine. ABSCESS AND FISTULA. 
443 
There should be but one treatment for this form of trouble, and 
that is an early and free use of the knife. It is a rule that an acute 
inflammation in this region will end in suppuration, and as soon as the 
brawny swelling appears it should be freely and deeply incised without 
waiting for pus. Pus will generally be present, however, before the 
surgeon is called. The treatment of such a case requires surgical skill. 
It is about as different from puncturing a superficial abscess and allow- 
ing the escape of pus through a small puncture as can well be conceived. 
The patient should be etherized and placed in the lithotomy posi- 
tion. A long, fine, straight bistoury should be inserted in the centre of 
the cutaneous hardness, pushed forward, and occasionally turned in the 
wound, till pus issues by the side of the blade. It may be necessary to 
carry the point fully four inches upward, and to repeat the puncture 
more than once before pus is found. In withdrawing the knife an 
incision two or three inches long should be made through cellular tissue 
and skin. Into this the index finger should be passed, all sloughing 
tissue broken down, all pockets opened up, till it is certain that a free 
communication of all parts of the abscess with the external wound has 
been established, and that the incision is sufficiently free to prevent any 
further burrowing. The cavity should then be irrigated with bichloride 
solution 1 :1000, and freely drained with iodoform gauze. 
These abscesses should not be laid open into the rectum unless when first seen 
by the surgeon it is found that the pus has already approached so near the cavity 
of the gut that there is no probability of avoiding an internal fistulous opening. 
The treatment is that of an abscess anywhere, and not that of fistula, for if seen 
early there is no fistula, and if boldly and properly treated the formation of a 
fistula may be avoided, though not in all cases. 
The superior pelvi-rectal space is bounded by the peritoneum above, 
the levator ani and its superior aponeurosis below, and the walls of the 
pelvis on the sides. It is filled up by lax pelvic connective tissue, 
which communicates in front and laterally with that which fills the 
iliac fossse and the deeper regions of the abdomen through the interven- 
tion of the subperitoneal connective tissue of the pelvic walls. Behind 
it is continuous with the connective tissue of the meso-rectum and the 
concavity of the sacrum, and it communicates with the gluteal region 
through the sciatic notch. In women it is also continuous with the con- 
nective tissue of the broad ligaments. 
It is easily understood from this why abscesses originating in this location may 
assume such vast proportions, burrowing laterally into the subperitoneal con- 
nective issue of the iliac fossae, or almost anywhere else in the true pelvis; dis- 
charging into the bladder, vagina, or high up into the rectum; mounting above 
the bladder and pointing in the groin or loin; passing out of the pelvis into the 
thigh, and causing retention of urine, and even intestinal obstruction, from 
pressure. 
In abscess of the pelvi-rectal space the symptoms are often obscured. 
There is more or less pain in the pelvis and lumbar regions, which is 
seldom intense. Fever may be entirely absent, is seldom continuous, 
and chills are only occasionally met with. The patient may soon sink 
into a typhoid condition, with high temperature and diarrhoea. I think 
I have more often been able to make an early diagnosis, before the dis- 
covery of tumor, by the presence of vesical and rectal tenesmus, with 
deep pelvic pain, than by any other signs. 444 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
The treatment is, of course, that by incision and drainage, and 
the incision should be made as soon as pus can be located. It is true 
that these abscesses tend naturally to discharge themselves into the rec- 
tum, vagina, or bladder, but to leave them to their own course is 
attended by great risk. If the pus be approaching the perineum, the 
Fig. 204. 
Pelvi-rectal flstulse : A, B, subcutaneous; C, D, submuscular (Potherat). 
incision should be made there ; should it appear in the groin or thigh, 
free incision may be made there; and should the tumor appear in the 
iliac fossa or above the bladder, laparotomy is indicated. 
Except when treated boldly and surgically the prognosis in these 
cases is not good. In the beginning the patient runs the risk of blood- 
poisoning, peritonitis, and phlebitis, and should the abscess find safe 
exit there are still all the risks involved in prolonged suppurative dis- 
ease. In the comparatively small number of cases in which sponta- 
neous healing occurs the risk of extensive cicatricial contraction remains ; 
and this may cause either stricture of the rectum or sigmoid flexure on 
the one hand, or fecal incontinence on the other. 
There is a form of periproctitis which is not to be confounded with 
this one. It is distinctly septic in origin, and is the chief cause of death 
after surgical operations in this region. It is analogous to puerperal 
septicaemia, and in its general symptoms follows closely the clinical 
history of pyaemia. 
In those cases in which the inflammation shows a tendency to become 
circumscribed, life may be saved by proper surgical treatment, but where 
it is diffuse and invades the intermuscular planes of connective tissue, 
there is little hope. 
I have seen infection start at the rectum, show itself as a brawny infiltration 
in the right iliac region, and extend up the right side to the axilla, without at 
any time becoming in the least circumscribed or allowing of surgical interference. 
Small fistulse of the subcutaneous variety, like the superficial 
abscesses from which they result, are generally easily curable by laying ABSCESS AND FISTULA. 
445 
open the track and scraping away with the handle of the scalpel the old 
grannlation-tissue which lines it. 
Fistulse resulting- from ischio-rectal abscesses differ greatly in 
their extent and gravity. In them the track is much larger, and often 
double or branching, and the external opening may be far away from 
the anus. The whole perineal region will sometimes be found brawny 
and indurated, and there may be a dozen or more points at which pus 
has burrowed to the surface. 
The fistulse resulting from abscesses in the superior pelvi-rectal 
space may be of any extent. The track may be very deep, and the 
probe passed into it may go directly away from instead of toward the 
rectum. Pus starting thus deep in the pelvis may find its exit in the 
groin, over the hip-joint, or even in the popliteal space. 
Fig. 205. 
Fig. 206. 
Complicated rectal fistula (Potherat) 
Complicated rectal fistula, same as Fig. 205, but 
more complete (Potherat). 
Tubercular fistulse are generally easy to diagnosticate by their 
gross appearance without microscopic examination. In them the 
internal orifice is apt to be large, so that the finger may readily pass 
into it from the rectum; the skin over the track is undermined; the 
discharge is sanious and unhealthy; and the general condition of the 
patient helps the diagnosis. In operating upon such cases the entire 
track, after being laid open, should be thoroughly destroyed, either with 
the sharp scoop or the cautery. There seems little doubt that such a 
fistula may be the starting-point of general tuberculosis, and that a 
radical operation done early may prevent general infection. 
A fistula may heal spontaneously or after a very slight excitement to repara- 
tive action, such as the mere passage of a probe in an examination. Such cases 
are, however, exceedingly rare. In certain cases a cure may also be effected by 
stimulating the track by injections of iodine, or by local applications of various 
caustics, or by the introduction of tents, etc. Treatment by any of these methods 
requires time and patience, and the result cannot be looked upon as at all certain. 
When it has been decided to lay a fistula open into the gut, there is 446 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
but one method to be recommended, and that is the knife. The elastic 
ligature or ecraseur need not be considered except in cases where the 
incision is so deep that concealed hemorrhage is to be guarded against; 
and the silk ligature is unsurgical. 
Where the fistulous tracks exist in great numbers, two or three ope- 
rations at intervals may be advisable, rather than an attempt to cure at 
one sitting. It is easily possible in such cases to do an amount of cut- 
ting that shall endanger the recuperative power of the patient. Many 
of the tracks will be found to run away from the gut and be merely sub- 
cutaneous, and it may be possible to divide the different openings into 
two or three groups, each group having its own independent deep com- 
munication with the bowel. 
Although to effect a cure in some cases it may be necessary to divide the sphinc- 
ters in two or three different places, and in such a greater or less degree of incon- 
tinence is to be expected, a double division of the sphincters is always to be care- 
fully avoided if possible. It is wonderful how many different tracks may be laid 
open and made to drain freely into a single median incision behind, if care and 
study be devoted to this point. Especially does this apply to the various forms of 
horseshoe abscess, in which pus has burrowed around the gut in a semicircle either 
in front or behind, and in which there are often two external and two internal 
openings. 
In all of these operations it is well to bear in mind that a large per- 
centage of all cases are failures, even in hospital practice. This arises 
from the popular conception that a fistula is a straight track leading from 
an external opening in the skin to an internal opening in the bowel, and 
that the operation consists in first passing a director along this track and 
then dividing it. On the contrary, most fistulae are branching, compli- 
cated tracks, which need to be dissected up and laid open with great 
care. The director needs only to be introduced a short distance at a 
time to do this, and many cases are better operated upon without a 
director. 
The after-treatment should be as simple as possible. After the first dressing 
of gauze has been removed, it is generally only necessary to pass a finger into the 
deep parts of the cut twice a week to see that it is open well down to the bottom 
and that no pockets have formed. 
Ulceration and Stricture. 
The simplest form of ulcer met with at the anus is what is univer- 
sally known as a fissure. Although almost invariably due to the trau- 
matism of a large and hard fecal movement, it probably may in a few 
cases be due to an ulceration of one of the sinuses of Morgagni and a 
thickening and tearing downward of the little valve of mucous mem- 
brane which forms the pouch. 
This is the explanation given by Ball of the frequent coexistence of fissure 
with an inflamed tag of skin at its lower edge, known as a “sentinel pile.” 
Next in frequency to the fissure comes the large class of ulcers due 
to traumatism, and the traumatism is generally surgical in character. 
Wounds of the rectum are proverbially hard to heal under the best 
treatment, and when neglected or badly treated change rapidly from 
healthy wounds to unhealthy ulcerations. 
In this way patients who have had slight operations for hemorrhoids or fistulse, 
and have passed out of observation with the wounds healthy and cicatrizing, will 447 
ULCERATION AND STRICTURE. 
return years later with extensive and incurable ulceration and stricture. So fre- 
quent is this that in every case of doubtful etiology the history in this regard 
should be carefully inquired into. 
Allied to these cases are those in which the traumatism is due to 
chronic constipation and the pressure of scybake upon the mucous mem- 
brane. Death has more than once been caused by perforation of the 
sigmoid flexure due to the pressure of a scybalous 
mass, and severe ulceration of the rectal pouch 
may be due to the same cause. 
Traumatism due to parturition is supposed to 
account for the much greater frequency of ulcera- 
tion and stricture in women than in men. Though 
the possibility of such traumatism cannot be de- 
nied, the greater frequency of ulceration and stric- 
ture in women may be doubted—at least if my 
own experience is of any value. For fifteen years 
I have kept an accurate table of all of these cases 
seen in private and hospital practice, and in the 
total (amounting to several hundreds) the male 
and female patients are about equal. 
There is another causative influence which is 
also peculiar to women, which I have seen sev- 
eral times. It is the pressure upon the rectum 
of a prolapsed and retroverted uterus. 
Tubercular ulceration may occur anywhere 
in the length of the alimentary canal, and is not 
very infrequent in the skin at the margin of the 
anus. It is characterized by its pale-red surface, 
covered with a small quantity of serum, but de- 
void of healthy pus, giving it a varnished appear- 
ance ; by the absence of surrounding inflamma- 
tion and the granulations which exist in a healthy sore; by its tendency 
to spread in depth rather than on the surface ; by the absence of pain ; 
by the irregular outline ending abruptly in healthy skin ; and, above all, 
by its chronicity and the utter failure of all ordinary remedies to affect 
its course. The diagnosis may be confirmed by the microscope. Tuber- 
culosis of the rectum or anus may be a primary affection, but is gen- 
erally associated with deposit elsewhere. 
Fig. 207. 
Diagram of the nervous con- 
nections between an anal 
fissure and the spinal cord: 
C D E, centripetal and cen- 
trifugal nerves (Hilton). 
Tubercular ulceration of the rectum is not generally a cause of stricture, there 
being too much destruction of the parts and too little cicatrization and inflamma- 
tory thickening to cause occlusion of the canal. It is, however, a not infrequent 
cause of fistula, the deposit and ulceration commencing in the mucous membrane 
and perforating the wall of the gut, causing an abscess in the surrounding cellular 
tissue which ends by again perforating the skin. Such a fistula is characterized 
by its internal orifice, which is so large that the finger used for rectal examination 
may pass directly into it without force. 
The ulcers resulting1 from dysentery vary much in extent and loca- 
tion, and, although their favorite site is at the rectum and sigmoid flexure, 
they may occur anywhere in the large intestine. I know of no way in 
which old dysenteric ulcers can be positively distinguished from chronic 
ulceration of other varieties except by the history of the disease, but I 448 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
am convinced that it is by no means an uncommon condition even in our 
Northern cities. 
It was for many years doubted whether dysenteric ulceration ever resulted in 
stricture of the rectum, but careful observation has collected a sufficient number 
of cases to set the question for ever at rest. 
There is still one other form of chronic ulceration of the anus, vulva, 
rectum, and vagina which has been described under various names, and 
which until within the past few years was supposed to be a distinct affec- 
tion. Perhaps the name by which it was best known was esthiomene. 
It has been attributed to syphilis and scrofula ; has been considered both 
as lupus and elephantiasis, and as an affection sui generis of unknown 
etiology. Nobody, I think, before R. W. Taylor grasped the fact, which 
was evident to him from his large experience in the venereal wards of 
Charity Hospital in New York, recognized that the greater number of 
these chronic, deforming vulvar and anal affections “ are due to simple 
hyperplasia of the tissues induced by irritating causes, inflammation and 
traumatism.” In other words, he fails to find any such disease as e.stliio- 
mene, but he does find that any lesion around these parts, especially in 
old syphilitic subjects, may take on a hypertrophic action. A chronic 
chancroid may do the same, and no venereal lesion is absolutely essential. 
The condition is recognized by the great extent of the ulceration, often 
destroying the rectum and vagina entirely; by its slow course, often last- 
ing many years without affecting the general health ; and by the great 
hypertrophy of the affected parts. It is most apt to be mistaken for can-r 
cer, 'phagedenic chancroid, or elephantiasis. 
The treatment should consist in destructive cauterization. In many 
of these cases antisyphilitic treatment will do good, but by no means in 
all. 
And yet the fact that the disease is sometimes a peculiar manifestation of syph- 
ilis is proven to my own mind by a case I once saw in which the disease was con- 
genital, was associated with other signs of inherited syphilis, and was greatly 
benefited and nearly cured by mercury and potassium iodide. 
There are also several varieties of venereal ulceration met with in 
the rectum and at the anus. 
Gonorrhoea of the rectum may be so severe as to cause distinct 
ulceration within the pouch, and the irritating discharge from the anus 
may cause erosions and fissures, or previously exising fissures may 
become inoculated and spread. 
Chancroids of the anus may be caused by direct contagion or by 
auto-inoculation, and, though they may be caused by unnatural vice, 
their mere presence is no proof of the habit. They are much more 
common in females than males, because of the facility of auto-inocula- 
tion and the frequency of accidental contact of the male organ. 
Although chancroid of the anus tends to spontaneous cure, and is usually a 
very superficial ulceration, it occasionally happens that the disease is attended by 
a certain amount of phagedena, and in such cases may extend within the rectal 
pouch, cause considerable destruction of tissue, and end in stricture. That this is 
the usual or even a common cause of the so-called “syphilitic” stricture of the 
rectum I do not believe. 
True chancre at the anus is not very uncommon, though it may pass' ULCERATION AND STRICTURE. 
449 
unnoticed. Its presence in the male is proof positive of unnatural vice, 
as the lesion is not auto-inoculable. 
True chancre within the rectal pouch has seldom been observed, though 
occasional cases are on record—one recently, which seems conclusive, by 
Hartley. 
Mucous patches are very frequent around the anus, and assume two 
distinct types, the ulcerative and the vegetating. It is to the latter 
alone that the so commonly improperly used term “condyloma” should 
be confined. 
Of the existence of secondary syphilitic ulceration within the 
rectal pouch there is no more doubt than of its existence in the fauces 
and trachea. There is also no doubt in my own mind that this form of 
ulceration may occasionally result in true syphilitic stricture ; but that it 
often does so, or that the so-called syphilitic stricture is really syphilitic 
at all, I do not believe. 
The time for jumping to the conclusion that because a patient has a stricture 
of the rectum which is not cancerous, he or she must have had syphilis, has gone 
by. There is, I think, no rarer lesion of the rectum than a syphilitic stricture. 
Syphilis undoubtedly causes stricture of the larynx and trachea, perhaps also of 
the oesophagus, but these constrictions are caused by the cicatrization of lesions 
which were primarily ulcerative. They are irregular cicatrices and salient bands 
which deform and occlude the organ, and they in no way resemble the masses of 
inflammatory deposit in the rectum which have been for so many years improperly 
regarded as a proof of syphilis. 
The argument against the syphilitic character of these old and extensive stric- 
tures is made still stronger by the fact that many of the sufferers have never had 
syphilis in any recognizable form, and by the additional fact that specific treat- 
ment is absolutely powerless to cause their resolution, though it has such a won- 
derful effect in other tertiary manifestations. To explain this failure, it is custom- 
ary to say that the period of infection is too remote from the trial of the drugs, 
that sclerosis of the rectum has already been established, and that specific treat- 
ment is powerless against sclerosis. But it is evident that there must be some 
period in the development of this disease, if it be syphilitic, at which specific 
treatment would have an effect, and clinically that period has never been found. 
Instead, therefore, of classing these old strictures as ano-rectal syphiloma, they 
should be described as examples of simple proctitis in which the secondary results, 
as hypertrophy, proliferation, and contraction, are present to an extent sufficient 
to cause occlusion of the canal. 
In thus enumerating the different varieties of ulceration of the rec- 
tum we have also enumerated most of the causes of stricture, which in 
the great majority of cases is a simple result of ulceration. Any simple 
ulceration of the rectum, if left to its own course, and more especially if 
badly or improperly treated, may result in a stricture from hyper ami ie 
overgrowth and contraction, and nearly all strictures not cancerous are 
of this nature. The only other varieties known are the congenital, the 
spasmodic, and those due to extensive traumatism or pressure from 
outside the canal. 
Congenital stricture of the rectal pouch is not very uncommon, 
and may not be discovered till the patient reaches adult life. For 
years the disease will cause little trouble, and the patient may only be 
aware of the fact that the passages are always very small in calibre; 
but as age advances the tissue composing the constriction becomes 
firmer, the difficulty in defecation increases, and finally a digital exam- 
ination reveals the nature of the affection. 450 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
Spasmodic stricture is very rare, and only, I think, associated 
with some other disease, as ulceration of the rectum. It has, however, 
been reported by good observers. By “ spasmodic stricture ” I mean 
an occlusion due purely to muscular contraction sufficient to prevent the 
passage of the finger without ether, and disappearing completely under 
an anaesthetic. 
Stricture due to the pressure of growths in the pelvis or the pelvic 
exudations or abscesses need not be considered at any length in this 
connection. 
Cancerous stricture is more common in the rectum than any other 
part of the alimentary canal. As its treatment is now the same as 
that of non-malignant contraction, no especial space will be devoted to 
its pathology or symptomatology. 
The treatment of ulceration of the rectum without stricture has 
come to be almost entirely operative when the ulceration has reached a 
point which lias involved any great loss of tissue. Only the slighter 
cases are curable by local applications. Superficial destruction of the 
mucous membrane, even over a considerable area, may be curable by 
proper local treatment, and a deep loss of tissue confined to a compara- 
tively small area may also be induced to cicatrize without very much 
subsequent contraction; but, unfortunately, the disease is an insidious 
one, and rapidly passes the curable stage. The choice often rests 
between colostomy and extirpation of the rectum. 
The treatment of stricture, both cancerous and benign, has also come 
at the present day to be entirely operative, and to consist either in 
colostomy or extirpation. In only a few of the simplest forms of non- 
malignant disease is the operation of division with subsequent dilata- 
tion of any permanent value, as the dilatation can seldom be main- 
tained at a point which will accomplish anything, on account of the 
irritation it produces. 
In deciding between colostomy and extirpation in any particular case, 
whether malignant or benign, the present tendency is to do an extirpa- 
tion when we can, and a colostomy when we must. 
Certainly this is the unquestioned rule in malignant disease; and if the 
mortality of extirpation could be still further decreased and the parts left in a 
little better condition functionally by further improvements in technique, it would 
also be the unquestioned rule in non-malignant cases. 
No argument is necessary at the present day to prove the advantages of colos- 
tomy in these cases. The only question now is whether extirpation in non-malig- 
nant cases offers sufficient advantages over colostomy to compensate for its great 
additional risk. 
In doing colostomy less preparation of the patient is necessary. In 
cases of prolonged obstruction delay is dangerous and purgation out of 
the question, and in others there is no occasion for emptying the aliment- 
ary canal. In fact, the presence of scybalous masses in the sigmoid 
flexure is one of the best guides to the part of the bowel to be opened. 
The parts should be scrubbed as in all laparotomies, and the incis- 
ion should be about two inches long, crossing an imaginary line from 
the anterior - superior spine to the umbilicus at a point one and a half 
Colostomy. COLOSTOMY. 
451 
inches from the spinous process. When the abdomen has been opened 
by this incision the sigmoid flexure, if in its normal position, will be 
the first loop of intestine presenting. Before searching for it, however, 
a silkworm suture with shot and shield on one end should be passed 
through all the layers of the abdominal wall from without inward at a 
point about half an inch from the inner lip of the wound, and the 
needle, still threaded, brought out through the incision and laid to one 
side. Search may then be made for the sigmoid. If it happen that the 
small gut present, the best place to search is between the incision and 
the anterior superior spine, close to the wall of the abdomen. Hook 
the finger into the wound and draw it along the abdominal wall from 
the side of the pelvis outward toward the incision, and the sigmoid will 
often be caught by it. 
When a proper piece of gut has been drawn through the wound, the 
needle is again taken up and passed through the mesentery of the loop 
close to the gut, and then through the whole thickness of the abdominal 
wall from within outward at a point half an inch from the incision on 
the side toward the spinous process. When this has been drawn taut 
and secured by a second shot and shield, the loop of gut will be securely 
held outside of the abdomen by a suture passing under it through its 
mesentery and through the whole abdominal wall on each side. 
The gut is next to be secured more accurately in its place by six or 
eight silk sutures passed as follows : The needle passes first through the 
skin at the margin of the incision; next through the cut edge of the 
parietal peritoneum; next through the muscular layer of the gut, but 
not into its calibre. When such a stitch is tied, it is evident that the 
gut will be attached to the skin margin of the incision, and that the 
peritoneal cavity will be closed by the union of the parietal and visceral 
layers at that point. 
Enough of these sutures should be used to completely shut off the peritoneal 
cavity. This part of the operation will be greatly facilitated if, when the peri- 
toneum is first incised, its cut edges be seized and held at half a dozen different 
points with forceps, and these be allowed to remain till replaced by the sutures. 
In this way the stitches can be replaced without wasting time in searching for the 
edge of the peritoneum. 
Before any suturing is done except the first suspensory suture of silk- 
worm gut, the loop of intestine should be drawn well out of the wound, 
and a longitudinal band selected through which the sutures can be passed 
for greater strength. One of these is always available, and not infre- 
quently use may be made of one on each side of the bowel. 
When the suturing is finished a loop of gut at least two inches and a 
half in length should be secured in the incision with one-half its calibre 
at least outside of the body, and the peritoneal cavity completely shut 
off around it. The gut may now be opened without waiting for adhe- 
sions. This is done by first snipping into its cavity with a pair of scis- 
sors, introducing a finger for a guide, and paring away the exposed wall 
down to within a quarter of an inch of the line of sutures. One or 
two small vessels may have to be tied. 
The appearance of the bowel after it is opened should be like that of a double- 
barrelled gun with a sharp ridge between the two barrels, where the gut is sharply 
bent over the silkworm suture. 452 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
The accepted practice for the past few years lias been to allow at least 
forty-eight hours to elapse between stitching the gut to the abdominal 
wall and opening it. Besides entailing a second slight operation, which 
is often attended by considerable dread and nervous shock, the practice 
is troublesome from the fact that the operator if at a distance from home 
is compelled either to wait two days or return. Five or six hours is 
amply sufficient to secure the shutting off of the general peritoneal cavity 
by exudate, but the writer has found even this delay unnecessary where 
proper care is given to the suturing, and now completes the operation at 
one sitting. 
The old practice of passing a couple of sutures directly through the calibre of 
the bowel and out again on the other side, then opening the gut, drawing them 
out from its interior, and cutting them so as to make two sutures on each side, is 
fatally defective in the fact that such a suture cannot by any possibility be aseptic 
at its point of exit, and hence stitch-abscess may be expected. 
Nothing need be said of the old operation of lumbar colostomy, except that it is 
much more difficult to perform, much less satisfactory in preventing the passage 
of faeces into the diseased part of the bowel, and can hardly be necessary under 
any circumstances. Any part of the large intestine except the caput coli can be 
brought to the incision in the left groin and fastened there. At least the writer 
has found by experience that both the ascending and transverse colon may be 
thus operated upon through this incision. 
One of the most troublesome complications liable to be met with is a 
sigmoid flexure practically without mesentery, and firmly bound down 
to the loin and brim of the pelvis, so that it cannot be brought out of 
the incision. In a marked case of this sort it is sometimes better to 
abandon the sigmoid and seek a more movable portion higher up. 
Hernia of the small intestine through the incision, even after the 
large gut has been stitched into it, is possible, and if not immediately 
discovered and replaced may be fatal. 
It is less liable to occur with the operation done as described than with the old 
plan of waiting forty-eight hours, and is much less liable to occur w7hen the gen- 
eral peritoneal cavity has been closed by eight or ten sutures, such as described, 
than when the operator has become carelessly confident and has about decided 
that so many sutures are unnecessary. The fact of having twice met with this 
accident has always prevented the writer from adopting the very simple plan of 
passing a glass rod under the gut to hold it in the incision, and dispensing with 
the sutures, as has been done in England. 
No surprise need be felt if the first movement from the artificial anus 
is delayed for several days, as the bowel has often lost its tonicity from 
chronic obstruction before the operation. 
After healing is complete the patient should always wear a broad 
abdominal belt and a pad of cotton over the opening, to prevent pro- 
lapsus. Trusses are seldom well borne. Care must also be exercised 
to prevent excoriation of the exposed mucosa. 
In non-malignant disease the prospect of cure and subsequent closure 
of the artificial anus should always be held out to the patient. It will 
give great comfort, and it may be done in any one of several ways, but 
is a more difficult operation than the original one. 
Finally, these patients will soon find that a person may be very comfortable 
with an artificial anus in the left groin ; and the higher the patient’s social condi- 
tion, and the more care he is able to give to his person, the more comfortable will 
he be. With such the annoyance of the artificial anus is apt to sink into insignif- 
icance in comparison with the result hoped for from its formation. The laboring- 453 
EXTIRPATION OF RECTUM. 
man is the worst sufferer, because he is apt to get a hernia at the site of the wound, 
and because he does not or cannot care for himself as he should. 
Extirpation of Rectum. 
At least four days should be allowed in which to prepare a patient for extirpa- 
tion of the rectum. On the evening of the first day, three compound cathartic pills 
should be given, and these should be repeated on the evening of the second. The 
day before the operation the diet should be exclusively milk and beef tea, preferably 
the latter, and on the evening before, a dose of bismuth and morphia should be 
given. This should be repeated on the morning of the operation. The idea of 
this preparatory treatment is plainly to have the alimentary canal as empty as 
possible before operating, and to postpone as long as possible the first movement 
of the bowels after the operation. 
No preparation of the site of the operation is made before the ether 
is given, but then great care should be devoted to this point. With the 
patient in the lithotomy position the perineum is first shaved and the 
rectum thoroughly cleansed. This is done through a speculum with 
frequent irrigations of bichloride solution (1 : 500), and by carefully wip- 
ing out the canal as high up as possible with pledgets of iodoform gauze 
on long forceps. 
Very often it will be a great help to the operator to introduce his finger into 
the canal during the operation, and in any case it will be necessary to cut the 
bowel across above the disease. In doing either of these things the whole wound 
is apt to become infected, and the object of the preliminary disinfection is to 
reduce this risk as much as possible. The disinfection may not be chemically or 
theoretically perfect, but exactly in proportion to its thoroughness will the mor- 
tality of the operation be decreased. 
A small tampon of iodoform gauze may be left in the rectum, but too great a 
mass distends the canal, obscures the limits of the disease while operating, and 
distorts the normal anatomy. 
The patient is next turned on the face or practically so, and the whole 
site of operation scrubbed and disinfected. Soap and brush, if well 
applied, with a final washing of bichloride, and after that of ether, will 
be found efficient. 
The incision should be begun at a point two inches to the left of the 
middle of the sacrum, slanting it toward the median line, and on reach- 
ing it extended along the fold between the buttocks to the anus. This 
incision should be made to reach bone at once, and flaps should be turned 
to each side by a few strokes of the knife. The right flap should freely 
expose the lower right half of the sacrum, that on the left the ligaments 
connecting the sacrum with the rest of the pelvis, and these should be 
divided. A periosteal elevator is then passed under the sacrum from 
left to right (the operator stands on the left) at the level of the incision 
to be made across that bone, and is worked down under sacrum and 
coccyx till the anterior surface of the bone is freed from soft tissues. 
In this way very troublesome hemorrhage from the sacra media and its 
veins may be avoided. When the periosteal elevator has been removed, 
one blade of a long, strong, straight bone-forceps is passed under the 
sacrum, and the bone is divided transversely, the lower fragment, with 
the coccyx, being completely removed. Usually this triangular piece 
should consist of the last two sacral vertebrae and the coccyx. 
All of this preliminary work should be finished in less time than it 
takes to describe it, and only slight bleeding will be caused by it. This 454 
DISEASES OE THE RECTUM AND SIGMOID FLEXURE. 
may generally be disregarded, and will cease spontaneously unless some 
of "the veins of the sacral plexus have been injured. Should there be a 
persistent loss of blood from just under the stump of the sacrum, it 
must be controlled either by forceps or pressure with the finger, as it is 
often exceedingly difficult to get a ligature under this point. A ligature 
on a needle will sometimes do what cannot be done in any other way, 
but forceps are generally sufficient. Particular attention is called to 
this minor point, as it is often a troublesome one. 
The pelvis being now freely opened, the operation may proceed. 
First, the gut should be isolated on each side by the finger; no cutting 
is necessary. In part the gut will roll out of its bed with great ease, 
but it will not come down, and the finger cannot be passed completely 
under it, for this is its largest part, and it is still firmly held by the 
peritoneum and connective tissue between it and the sacrum. The key 
to the rest of the operation is the peritoneum, which should be found 
and opened before any attempt is made to drag down the gut. This 
may take time, and several small incisions maybe made into the cellular 
tissue covering the peritoneum before its cavity is opened ; but when the 
finger is once fairly within the free peritoneal cavity the greatest diffi- 
culties in the operation have been overcome. I usually make the open- 
ing into the peritoneum on the right side of the gut, introduce the finger, 
hook it under the gut, and force it out through the peritoneum and cel- 
lular tissue again till its end appears free on the left side of the rectum. 
In this way the fold of Douglas is torn open and away from the bowel, 
and the rectum is prevented from coming down only by the mesoreotum 
and cellular tissue between it and the hollow of the sacrum. While 
gentle tension is made upon the gut with the finger hooked under it, this 
last obstacle to its free descent may be cut away. 
The mesorectum must be cut as little as possible. If it be stripped 
off from the gut to too great an extent, the bowel will slough for lack 
of nourishment. It is generally easy to feel, before the gut is opened, 
the extent of the disease to be removed, and the rectum should be cut 
across above it—if for cancer, at least an inch above. No bleeding need 
be feared from cutting across the gut. Unfortunately, it will often be 
found only too feebly supplied with vessels after the mesorectum has 
been cut sufficiently to allow the stump to come down into the wound. 
Something much more to be feared is soiling the wound with the con- 
tents of the bowel. This may best be avoided bv dividing it between 
two ligatures made of gauze, or between two intestinal clamps, after the 
wound has been carefully protected by packing with gauze to be subse- 
quently thrown away. The upper end after division should be carefully 
wiped with iodoform gauze, and given to an assistant; the lower end 
should be seized firmly by the operator, stripped quickly from its 
anterior attachments by pulling it downward and outward, and either 
removed as a whole or amputated below the disease. If it be removed 
down to the anus, the levator will need to be cut on each side. 
The operator now has the whole pelvic cavity at his command. In women, 
tubes, ovaries, and uterus can be plainly seen and easily examined. Several times 
I have removed tubes and ovaries at this stage of the operation where their removal 
was imperative, but I prefer not to do it. The shock of an extirpation may be 
more than a patient can bear, without any additional traumatism. EXTIRPATION OF RECTUM. 
455 
The next point to be decided is what to do with the upper end of the 
gut—whether to bring it down to the skin and make an anus in the 
natural place in the perineum, to suture it to any portion of the rectum 
which may have been preserved near the anus, or to bring it out in the 
middle of the wound and suture it to the skin just below the stump of 
the sacrum. 
This is often a very difficult point to decide, and one upon which not 
only the subsequent comfort of the patient, but also his life, may depend. 
If it is determined to bring the stump down to the skin of the perineum,, 
a trial must be made to see if it is sufficiently long and movable, and if 
not, the mesentery and cellular tissue must be divided a little more 
freely. 
After this has been decided the toilette of the peritoneum should be 
made with hot water or saline solution and sponges, exactly as in a 
laparotomy. The end of the gut should then be stitched to the point 
decided upon, all parts of the wound should be closed by deep and super- 
ficial sutures as carefully as possible, and a tent of gauze should be left 
in the deep part for drainage. Almost always the suturing will stop all 
bleeding, and no time need be devoted to special suture of the rent in 
the peritoneum. 
When the anal portion of the rectum has been removed with the rest, there is 
apt to be a free and continuous oozing of blood from the bed in which the lower 
rectum lay. There is no spurting vessel and nothing to tie, and yet there may be 
lost a good deal of blood. This is best controlled by deep sutures, drawing the 
sides of the cavity together. 
It is evident that this is an operation of precision, very different from 
the more or less blind plunge into the perineal region formerly in vogue. 
It can be completed by a rapid and experienced operator in about forty- 
five minutes, while one unfamiliar with it may spend three or four hours 
in controlling hemorrhage which, if left to itself, would cease without 
ligatures. 
Many complications may arise during its performance. 
One of the most awkward I ever personally encountered was to find a rectum 
absolutely without mesentery and bound immovably to the hollow of the sacrum 
by connective tissue. All attempts to bring it down resulted simply in tearing up 
one of the longitudinal bands, and at the end I held in my hand simply six or 
eight inches of stripped and injured gut, without any source of nutrition. During 
a great part of the operation a loop of large bowel, the upper part of the sigmoid 
flexure, had been hanging loosely in the field and occasionally coming in the way ; 
and it finally occurred to me that this would answer my purpose as well as any- 
thing else. It was therefore stitched to the edges of the incision and opened much 
as in an inguinal colostomy. The end of the gut beyond the artificial opening was 
arranged so that none of its contents could escape into the wound, and the patient 
recovered with as useful an anus as is customary. 
Regarding the final disposition of the end of the gut where it lias 
been cut off above the disease, there are many things to be considered. 
The safest and simplest operation is the old one of stitching it to the 
skin just below the stump of the sacrum. This does away with much 
of the danger of sloughing, and hence reduces the mortality, but leaves 
an anus that is not as satisfactory to either patient or surgeon as one in 
its natural place. 
In cases of cancer, where all questions of future comfort are as nothing com- 
pared to the great one of saving life by removal of the disease, it may be perfectly 456 
DISEASES OF THE RECTUM AND SIGMOID FLEXURE. 
proper to disregard the minor point of future functional control, and aim simply 
to save life with the least possible risk. But in cases of non-malignant ulceration 
and stricture demanding excision the subsequent condition of the patient will be 
found a matter of more consequence. The surgeon may know he has as surely 
saved the life of such a patient as though he had removed a cancer; but the 
patient may not appreciate it, and may be tempted to compare his last state with 
his first, even though he may have gained many pounds in weight and be cured 
of his disease. 
Doubtless the theoretically perfect operation is the one that removes 
the disease and leaves the patient with as good functional control as he 
had before; and this may frequently be accomplished both in cases 
where the disease has been confined to the lower end of the gut, and 
where after amputation of two or three inches the stump can be stitched 
to the skin of the perineum; and in cases of disease quite high up 
which allows room after resection for careful apposition of the two ends. 
But this last operation is attended by many failures, and more risk than 
either bringing the stump down to the skin of the perineum or turning 
it sharply backward just below the stump of the sacrum. The upper 
segment is poorly supplied with nourishment, and the lower has no 
peritoneal investment. The most careful suturing will fail of its 
object, and the Murphy button will slough out. In either case the 
whole wound becomes foul with faeces, and the mortality is greatly 
increased. 
This risk is unquestionably greatly reduced by preliminary colostomy. 
In deciding upon the final disposition of the stump of the bowel, the 
operator will be chiefly guided by its vitalization and the extent to 
which the mesentery has been injured in loosening the rectum. In 
some cases it will evidently be so impoverished that it can only be 
brought out in the sacral region. 
Absolute sphincteric control should never be promised after extirpation. 
Few patients have it before the operation, and fewer still will have it 
after. The most that can be hoped for is that the patient will be as 
comfortable after as before in this regard, which means that he will 
know when an evacuation is impending and have time to attend to 
himself. 
When the stump has been brought down to the perineum and a fecal fistula 
still remains at some point in the line of incision, there is always a chance for 
a successful operation to close the latter. The gut itself should first be dissected 
loose and closed by a Lembert suture, and then the skin should be closed over the 
opening. Attempts at closure of such fistulse by plastic operations on the skin 
alone, leaving the opening in the gut to care for itself, have generally not suc- 
ceeded. 
Such in a general way is the operation for extirpation of the rectum, 
either cancerous or strictured and ulcerated, and the secret of its mor- 
tality will be found to lie much more in perfect antisepsis than in the 
amount of shock. 
My own first statistics showed the full death-rate of 30 per cent. This has 
been gradually reduced until during the past winter I had only 1 death in 13 
cases, the last 12 being uninterruptedly successful. That the improvement has 
been due solely to increased care and better technique I have no doubt. A suc- 
cessful case will now leave the hospital in about three weeks, and I have had 
patients sitting up in bed at the end of one. CHAPTER XI. 
GENITO-UBINARY SURGERY. 
William T. Belfield, M. D. 
Malformations . 
Prepuce.—The foreskin exhibits three common abnormalities—undue 
length, tightness, and adhesion to the glans penis. These three features 
are commonly combined in congenital phimosis, or inability to retract 
the prepuce behind the glans. This condition—and the accumulation 
of smegma under the foreskin which commonly accompanies it—is 
responsible for many morbid states : it causes in childhood local irrita- 
tion and soreness, straining and pain in urination, and a tendency toward 
hernia (in every case of acquired hernia in children the prepuce should 
be examined, and, if phimosis exist, removed as a part of the treat- 
ment of the hernia). In certain cases, disorders of the nervous system, 
such as convulsions, epilepsy, chorea, and paresis, have ceased after the 
removal of a tight prepuce. In later life phimosis favors balanitis, 
unnatural excitability of the sexual organs, as shown by frequent emis- 
sions and nervous phenomena, and it greatly increases the danger of 
venereal infection. 
For these reasons phimosis should be promptly relieved by circum- 
cision whenever brought to the physician’s attention. 
Penis.—Absence of the penis, except as the result of disease or injury, 
is very rare, and is always associated with arrest of development in 
adjacent organs. Apparent absence of the penis at birth is less rare, 
and is due to a misplacement of the organ, which may be detected as a 
firm cylinder beneath the skin of the scrotum, perineum, or suprapubic 
space. It can be liberated by suitable incision and restored to its nor- 
mal position; a proper covering can be secured by plastic operation. 
Rudimentary and multiple penis have been occasionally observed. 
Absence of the urethra, which is replaced by a fibrous cord, occa- 
sionally occurs. This usually results in the death of the foetus before 
the completion of intra-uterine life, because the distended bladder presses 
upon the umbilical arteries and thus impairs the nutrition of the foetus. 
Yet in a few instances such a child has been born alive; in some of 
these it is found that the urachus has reopened and serves as a urethra; 
in others the recto-vesical partition is imperfect; while in a third class 
the bladder is found enormously distended at birth and needing imme- 
diate surgical treatment. Occasionally such a bladder has formed an 
obstacle to delivery until punctured. For practical purposes this con- 
dition is identical with the following : 
457 458 
GENITO- URINARY SURGERY. 
Congenital Occlusion (Atresia) of the Urethra.—This results from 
a fusion of the urethral walls over a small area, and is most common in 
the vicinity of the meatus and often associated with hypospadias. Atten- 
tion is attracted by the child’s failure to urinate and by the distention 
of the bladder. Examination may show an occluded meatus, which 
should be incised; a small button probe is gently passed backward to 
the bulb, unless the urine flows before that point is reached ; if further 
separation is needed, the probe is replaced by a small elastic catheter, 
with which a gentle effort is made to overcome the obstruction. 
Sometimes these eftbrts have failed to reopen the urethra: the surgeon must 
then tap the pervious portion of the urinary channel, either the bladder itself or 
the distended portion of the urethra; from this point of vantage attempts may be 
made to pass instruments from behind forward along the urethra. It should be 
remembered that in such a child there probably exists distention of the ureter, 
hydronephrosis, and pressure atrophy of the kidney, from which causes death may 
ensue even when the urethral canal has been re-established. 
Congenital urethral pouches are rare distentions of the floor of the 
penile urethra, holding from an ounce to a pint of urine; though appar- 
ently resulting from an impediment to the escape of urine, such obstacle 
has not usually been detected in the cases examined. It is possible that 
the impediment was a temporary barrier (occlusion) between the penile 
and glandular urethra, which has been broken through after the forma- 
tion of the pouch. 
Tiieatment consists in excising the redundant skin and mucous 
membrane, leaving just enough to form a urethra of natural calibre by 
apposition ef the cut edges. 
Hypospadias and epispadias are terms designating congenital 
defects in the urethral walls, as a result of which the urine escapes from 
the penis at some point posterior to the normal exit, the meatus. 
These defects are probably due to the conditions already described— 
congenital occlusion and pouching of the urethra, followed by rupture 
of its walls prior to birth, and cicatricial contraction of the ruptured 
edges, often with adhesions to the scrotum, which sometimes cause a 
turning or “torsion” of the penis on its axis. 
The commonest locality for congenital occlusion is at the junction of 
the glans penis with the spongy urethra, for these two portions are sepa- 
rately developed, the penile urethra growing forward from the pubic 
bone, the glandular urethra dipping backward from the tip of the glans. 
These two blind canals normally meet at the posterior surface of the 
glans, and coalesce through the absorption of the intervening tissue. 
If, however, this coalescence into a complete canal be prevented by the 
persistence of a barrier of intervening tissue, various abnormal sequences 
may occur: (1) simple congenital occlusion; (2) pouching of the penile 
urethra behind the barrier; and (3) rupture of the distended urethra, 
resulting in hypospadias if the rupture be, as it usually is, on the under 
surface; and in epispadias if the rupture occur on the upper surface of 
the urethra. 
Hypospadias is a common deformity occurring in one out of every four or five 
hundred males. It is designated as glandular, penile, or perineal according as the 
abnormal urethral opening is in the glans, body of the penis, or perineum: the 
commonest locality is just behind the glans. In any case the urethra anterior to 
the opening is represented by a groove on the under surface of the penis, except that MALFOBMA TIONS. 
459 
occasionally the part contained in the glans is perfect. There is usually a marked 
deflection of the glans from the normal line, and often a deformity of the prepuce; 
the entire penis is apt to be of small size and have a downward curve; adhesions 
to the scrotum are not rare. 
Fig. 208. 
Diagrammatic sections showing different varieties of hypospadias (Kauffmann): 1, hypospadias 
with imperforate glans; 2, hypospadias with blind canal in glans; 3, with barrier placed 
between penile urethra and balanitic groove ; 4, typical case of hypospadias; 5, hypospadias 
with normal meatus ; 6, penile urethra opening below glans; 7, absence of the whole inferior 
part of the penile urethra; 8, hypospadias with absence of urethra through glans; 9, case of 
D’Arnaud; 10, case of Lacroix ; 11, case of Lippert with normal meatus. 
If the abnormal urethral opening lies behind the scrotum, this sac is 
split into two, which may be widely separated. In this case the appear- 
ance of the external genitals—especially when the testicles are unde- 
scended—simulates more or less perfectly that of the external female 
organs; hence the individual is often considered an hermaphrodite. 
Closer examination, however, enables one to recognize in the adult the 
distorted male organs, and a finger in the rectum detects the prostate, 
though this may be smaller and thinner than usual. Nearly all the pro- 
fessed hermaphrodites, including the individuals who exhibit themselves 
at medical schools under this name, are merely males displaying an 
extreme degree of perineal hypospadias. 460 
GENITO- URINAR Y SURGER Y. 
In infancy, however, especially if the testicles have not descended, resemblance 
to the external organs of the female is so great that these subjects of perineal hypo- 
spadias are often brought up as girls; their true sex remains unsuspected until 
puberty, when the development of masculine characteristics of figure, voice, and 
beard iead to a discovery of their masculinity. 
Hypospadias causes a disturbance in urination proportionate to the degree of 
deformity: in the glandular form this is slight, while in the perineal variety the 
individual cannot project the urine, and is therefore compelled to assume the sit- 
ting posture in urination. 
Epispadias, caused by the rupture of the upper surface of the foetal 
urethra, is far less common than hypospadias. A few instances of epi- 
spadias limited to the glans penis or in the anterior portion of the penile 
urethra, have been recorded; usually, however, the defect of the upper wall 
is associated with a similar defect in the bladder and abdominal wall and 
an imperfect union of the symphysis—the condition known as exstrophy 
of the bladder. 
Epispadias involving the deep urethra usually occasions great distress to the 
patient because of the inability to retain the urine, for the deep urethra is nor- 
mally the chief sphincter of the bladder. 
Bladder.—Absence of the bladder has been detected post-mortem in 
a few instances, but has no clinical importance. 
Division of the bladder by a more or less complete septum is likewise 
a rare condition, which might, however, puzzle the surgeon in case of 
calculus-formation in one of the cavities. 
Hernia of the bladder is a by no means infrequent condition, the pos- 
sibility of which should not be forgotten in considering tumors at the 
various pelvic outlets, particularly the inguinal canal. 
Hernia of the bladder into the inguinal canal or even the scrotum of 
the male, with or without intestine, omentum, or an undescended testicle, 
has repeatedly surprised surgeons when operating for a supposed intes- 
tinal hernia. Skilful operators have opened the bladder in this locality, 
discovering their mistake only through the escape of urine. The pos- 
sibility of vesical hernia as the cause of an inguinal swelling is suggested 
if the tumor be soft and elastic, and if the patient be suffering from 
cystitis or retention of urine. Pressure and manipulation of the tumor 
may cause its disappearance, accompanied by a desire to urinate on the 
part of the patient. Vesical hernia must be especially distinguished from 
hydrocele of the cord. 
Hernia of the bladder, by preventing proper evacuation of the organ, favors 
the occurrence of cystitis and of calculus, the latter often located in the incarce- 
rated portion of the bladder. It should be treated on the same principles as govern 
the treatment of intestinal rupture. 
Hernia of the bladder through a congenitally patent urachus has been rarely 
observed; the perviousness of this canal, without vesical hernia, is a more com- 
mon affection. It should be treated by removing any obstruction to the exit of 
urine through the normal passages, or by artificial drainage through a perineal or 
suprapubic incision ; after which the usual means for closing a fistulous opening— 
destruction of the lining epithelium by the actual cautery or chemical caustics— 
may be employed. 
Inversion of the bladder through the urethra is a form of hernia occa- 
sionally observed in females as the result of violent straining; it is easy 
of recognition if the possibility of this condition be borne in mind. 
The bladder can be returned to its normal position under anaesthesia, 
but great care to prevent its recurrence must be observed. MALFORMA TIONS. 
461 
Exstrophy of the bladder is a congenital absence of the anterior wall 
of the bladder, frequently associated with separation of the pubic sym- 
physis and defect of the upper wall of the urethra; it is probably due 
to the same causes as epispadias, already described. The patient’s con- 
dition is deplorable : the constant escape of urine, soon becoming ammo- 
niacal, the excoriations of the skin as well as of the exposed bladder, 
contribute to a condition of constant suffering. 
Treatment consists either in the wearing of a specially constructed 
urinal or in a plastic operation for the restoration of the defective tissues. 
Kidney and Ureter.—Absence of one kidney is said to occur once in 
about four thousand cases: in at least one recorded instance a surgeon 
has removed the only kidney possessed by the patient, who presently died 
of suppression. Fortunately, the cystoscope now enables us to deter- 
mine whether both kidneys are secreting urine. 
Fusion of the kidneys, partial (horseshoe kidney) or complete, is an 
anomaly of little surgical importance. 
A valve-like obstruction of the ureter at its junction with the kidney 
pelvis is the only congenital malformation of this duct possessing sur- 
gical importance. This valvular arrangement is apparently due to the 
insertion of the ureter into the pelvis at an improper angle, and its result 
is hydronephrosis. 
A similar obstruction, due to “kinking” of the ureter, is occasionally observed 
as the result of displacement of the kidney and a consequent sharp bending of the 
ureter in its upper part. 
Testicle and Vas Deferens.—Absence and multiplicity of these organs 
possibly occur, but with exceeding rarity. 
A eunuchoid condition of the testicle is sometimes observed, the organ 
being of small size and lacking the normal glandular elements. Retained 
testicles exhibit this condition oftener than do those which have descended 
into the scrotum. 
Misplacement of the testicle, due to irregular or incomplete descent, is 
a frequent and important malformation. The organ may be found in 
the abdomen (cryptorchidism), the inguinal canal, at the external inguinal 
ring, in the perineum or crural region. In any of these abnormal loca- 
tions, except the abdominal cavity, the misplaced testicle constitutes a 
swelling which has often been mistaken for hernia, bubo, or abscess (the 
latter when the testis is inflamed by a gonorrhoeal extension or other 
cause). Hence the surgeon should make a practice of examining the 
scrotum in every case of disease of the pelvic organs, that the misplace- 
ment of one or both testicles may not be overlooked. A misplaced 
testis can usually be recognized as such not only by its form and size, 
but also by the peculiar sensation caused by pressure upon it. 
Misplaced or undescended testicles do not usually exhibit the perfect structure 
or function of the naturally placed organ: they are often found in a fibroid 
(eunuchoid) state, especially in middle life, secreting imperfect spermatozoa or 
none at all, though in the young such testicles have been sometimes found normal. 
If both testes be thus misplaced, the individual is sterile, though possessing normal 
sexual appetite and vigor; if only one testicle be undescended, the other, if nor- 
mal, furnishes the spermatozoa essential to fertilization of the ovum. 
Misplaced testicles, especially when retained in the inguinal canal, 
and hence subject to a continuous abnormal pressure, are especially prone 462 
GENITO-URINARY SURGERY. 
to become the seat of malignant disease—an argument in favor of opera- 
tive interference. 
If the testicle be retained in the abdomen, no treatment is required; 
if it be found in any other abnormal location, it should be transplanted 
to the scrotum when possible. If this be prevented by adhesions or 
shortness of the cord, its removal should be advised, provided the other 
testicle be found normal. While the patient, when young, will usually 
object to such removal, yet the frequent annoyance and pain from the 
misplaced organ will gradually convince him of its advantages. 
Injuries of the genital and urinary organs require no treatment other 
than that which aseptic surgery prescribes for injuries in general, except 
in so far as such injuries may open the urinary channels ; for the reten- 
tion in the tissues of urine which has escaped from the normal channels 
is followed by severe local sepsis, with the ever-present danger of general 
septic infection and intoxication. On the other hand, normal urine may 
pass through or over any of the abdominal or pelvic tissues, even the 
peritoneum, without especial injury or danger. 
It is therefore the stagnation of urine in the tissues which must be 
carefully avoided in the treatment of injuries that open the urinary canal 
—if possible, by the prompt closure of the wound in the canal, and in 
any case by provision for the free escape of such urine. If such drain- 
age is provided, the same immediate results may be expected after 
injuries of these as of other organs: as to the ultimate results, it must 
be remembered that any channel through the tissues along which the urine 
has long been allowed to flow is apt to become lined with epithelium 
and constitute a permanent urinary fistnla. Hence it is desirable to 
close such wounds so soon as this can be done without danger of urinary 
infiltration. 
Penis and Urethra.—In treating injuries of the penis the great 
vascularity of that organ must be remembered and care be taken to 
arrest and prevent hemorrhage. Aside from wounds in general, which 
need no description, the penis is sometimes the subject of strangulation, 
dislocation, and fracture (so called). Strangulation occurs in boys or 
men from tying strings or bands around the organ or introducing it 
through rings or into bottles: great swelling, even gangrene, has been 
known to ensue. Occasionally strangulation has been seen to follow 
paraphimosis. 
Treatment naturally consists in removing the constricting band 
and in the liberal application of hot water to the swollen parts. 
Fracture of the penis means a subcutaneous laceration of the erectile 
bodies, usually the corpora cavernosa, and occurs through violence 
inflicted on the rigid organ. It was often the result of an attempt to 
“ break ” a chordee by striking the erect penis, previously laid upon a 
table, with a book or other object; and it has been known to result from 
“ missing the mark ” in attempts at intercourse, the penis striking vio- 
lently against the pubic bone of the female. 
If neither skin nor urethra be lacerated, the hemorrhage from the torn vessels 
of the corpus cavernosum makes a subcutaneous swelling which should be treated 
Injuries. INJURIES. 
463 
with continuous hot fomentations. If, as more commonly happens, the urethra 
also is lacerated, profuse, even alarming, bleeding from the meatus ensues: this can 
be checked either by simple compression of the penis or better by compression 
against a large metal sound introduced into the urethra. For a day or two follow- 
ing this accident urination is apt to be difficult or even impossible, and the effort 
starts the bleeding again. Urinary infiltration is apt to occur, requiring free incision 
and drainage from without. 
Laceration of the corpus cavernosum is in any case usually followed by obliter- 
ation of some of the vascular spaces in that body, and consequent imperfection in 
erection thereafter, the penis bending when erect toward the injured side. 
Dislocation of the penis is a rare result of violence to these parts : the 
organ has been found displaced under the skin of the perineum, abdomen, 
or thigh. It should be immediately 
restored to its normal position and 
covered with skin, its own or that of 
surrounding parts (scrotum),when its 
original covering has been destroyed. 
Injuries of the urethra may be 
clinically divided into those that do 
and those that do not extend through 
the skin, analogous to the compound 
and simple fractures of bones. 
Inj uries of the urethra combined 
with a wound of the overlying tis- 
sues and skin are usually inflicted 
by sharp instruments, and, because 
of the external opening, offer but 
little danger of urinary infiltration, 
though they may bleed profusely. 
Longitudinal ivounds of the urethra 
heal whether sutured or not; trans- 
verse wounds should be sutured with 
catgut whenever possible. This is 
best done, after enlarging the wound 
if necessary, over a large catheter in 
the urethra. Sometimes the wound 
may have completely severed the 
urethra, rendering the introduction 
of a catheter difficult or impossible. 
Fig. 209. 
In this case, if the patient urinate 
freely through the wound, the surgeon 
may wait until the first swelling has sub- 
sided and then again try to pass the 
catheter ; if, however, there is infiltration of urine, the sound urethra behind the 
point of injury should be made accessible—either by perineal urethrotomy or 
suprapubic cystotomy—and a catheter passed from behind forward, on which the 
urethra can be sutured. The tissues above the urethra may also be united, but a 
small drain should be left to prevent urinary infiltration. Transverse lacerations 
of the urethra and all injuries involving the peri-urethral tissues are apt to be 
followed by stricture. 
Traumatic stricture of urethra (by fracture of 
pelvis), with resulting hypertrophy of blad- 
der-walls, ureteral dilatation, and hydrone- 
phrosis (Tuffier). 
Injuries of the urethra without perforation of the overlying skin are 
most common and often very serious. They occur in the penile urethra 
from fracture of the penis already described; from unskilful handling 
of metal sounds, catheters, and urethrotomes; from the introduction by 464 
GENITO-URINARY SURGERY. 
the patient of foreign bodies—needles, pencils, etc.; and from blows or 
falls. The less movable urethra posterior to the scrotum is, however, 
the most frequent site of such injuries, which result from the forcible 
use of urethral instruments, from blows and falls upon the perineum, 
and from fracture of the pelvic bones. Boys who have fallen astride of 
fences, limbs of trees, bicycle saddles, or other objects furnish a large 
share of these cases. 
In a case of contusion of the structures surrounding the urethra, 
laceration of this channel is usually indicated by the escape of blood 
from the meatus; if, however, the urethral tear is located behind the 
bulb, the blood may not appear until urination occurs. Retention of 
urine almost always follows—sometimes immediately, at other times 
within a day or two; pain and swelling at the seat of injury are regular 
features. 
The chief object of treatment is to prevent urinary infiltration of tissues: 
the methods for accomplishing this will vary with the locality and extent of the 
laceration of the urethra. In cases of slight wounds of the penile urethra the 
introduction of a scrupulously clean elastic catheter (without a wire) at necessary 
intervals, whereby the urine is withdrawn and the urethra irrigated with hot water, 
may suffice. In some of these lesions of the anterior urethra, and in most cases 
of urethral laceration posterior to the scrotum, there will soon occur, in spite of 
this measure, the signs of beginning infiltration of urine—burning pain and boggy 
swelling at the seat of injury, rise of temperature, and ultimately chills. 
So soon as the occurrence of symptoms justifies the belief that urine 
is stagnating outside of the urethra, the surgeon should insist upon 
making a prompt incision to the seat of rupture and instituting free 
drainage ; incidentally he should endeavor to suture the wound in the 
urethra. Early operation not only greatly diminishes the chance of 
general septic infection and death (which has occurred in about 12 per 
cent, of such cases), but also, by limiting the local destruction of tissue, 
reduces the subsequent cicatrix and stricture-formation to a minimum. 
Physicians are inclined to wait too long before operating in these eases. 
Surgeons have even operated immediately after the receipt of the injury, 
without waiting for signs of infiltration. 
If the laceration be in the deep urethra, the incision should be a perineal ure- 
throtomy, a drainage-tube being inserted into the bladder and retained for a week 
or ten days. In all cases where the urinary infiltration has been extensive, the 
continuous—or, if that be impracticable, the frequent—immersion of the parts in 
hot water is exceedingly valuable in cleansing the tissues and limiting the damage. 
Even the constant application of hot fomentations is useful when the immersion 
of the parts is for any reason impossible. 
While the attempt to suture the lacerated urethra will not always succeed, yet 
by patience and ingenuity the surgeon may bring an unexpected amount of order 
out of the chaos of blood, urine, and fragments of tissue which is at first revealed 
by the incision. 
The possible remote results of these injuries are extensive and obsti- 
nate stricture, urinary fistulse, incontinence of urine from destruction of 
the membranous urethra, and curvature of the penis during erection 
from destruction of portion of the corpora cavernosa. 
Bladder.—Injuries of the bladder may be clinically divided into two 
classes—those which do and those which do not perforate the wall of 
this organ. The latter usually proceed from rough instrumentation, 
and commonly result in nothing more serious than cystitis or possibly INJURIES. 
465 
sharp hemorrhage. Wounds involving the entire thickness of the 
bladder-wall are, on the other hand, most serious injuries, generally 
requiring prompt operative treatment. They are made directly by 
knives, bullets, fragments of fractured pelvic bones, etc. and indirectly 
by blows upon the hypogastric region, which compress the bladder 
when distended—the so-called “ rupture of the bladder.” 
The danger from such injuries lies of course in the extravasation 
and stagnation of urine, either in the peritoneal cavity or in the exten- 
sive connective tissue of the pelvis which is subjacent to the peritoneum ; 
in either case rapidly fatal septic infection and peritonitis are imminent. 
On the other hand, if the wound itself afford free exit to the urine, as 
when a bullet passes into the bladder or a stick is driven from the rectum 
or vagina into this organ, a free escape of urine resulting, septic infec- 
tion often fails to appear. 
It follows, therefore, that the first and immediate object of treatment 
in all injuries by which the bladder is opened is to provide free escape 
for the urine. This may be secured by the insertion of drains through 
the wound itself; in other cases the wound must be enlarged and 
explored. Frequently the bladder should be opened by suprapubic 
incision, through which an attempt to close the wound in its wall can 
be made as well as perfect drainage secured: the exact measures to be 
taken must be determined in each case. 
Rupture of the bladder usually results from violence to the supra- 
pubic region when the bladder is more or less distended; in a few 
instances such rupture has occurred from violent straining and from 
distention of the organ by the surgeon as a preparation for suprapubic 
cystotomy. The possibility of this accident should be remembered in 
any case of injury to the lower abdominal region. 
Ruptures of the bladder are practically divided into intraperitoneal 
and extraperitoneaf, according as the tear does or does not involve that 
portion of the bladder covered by peritoneum. Intraperitoneal ruptures 
have all resulted fatally, usually within three days, unless promptly 
sutured after laparotomy; extra peritoneal ruptures are less certainly 
fatal, though the large majority die in a few days unless operated on. 
It is evident, therefore, that even a decided probability of bladder rupture 
justifies an exploratory incision, which is far less dangerous than the delay often 
necessary before a positive diagnosis of rupture can be made. The surgeon should 
certainly never hesitate to operate when the first signs of septic infection become 
apparent. 
Symptoms.—These are by no means constant. Sometimes there 
occur frequent and painful micturition of a few drops of bloody urine, 
the catheter revealing an empty bladder, great pain and tenderness over 
the bladder, and signs of collapse. Yet in individual instances any of 
these signs may be absent: the patient may even pass fair quantities of 
clear urine; on the other hand, all the above symptoms may be present 
without rupture of the bladder; sometimes a catheter is felt to pass 
from the bladder into a cavity beyond, but this fortunate proof of blad- 
der rupture is rare. Probably the most reliable test is the injection into 
the bladder of hydrogen gas, or, in its absence, of air: if there be an 
intraperitoneal rupture, no apparent distention is produced ; if an extra- 
peritoneal tear exists, an irregular distention of the suprapubic space 466 
GENITO- URINAR Y SURGER Y. 
follows; if the bladder be intact, the familiar pear-shaped distention 
ensues. 
Treatment.—So soon as the diagnosis of bladder rupture becomes 
probable—even though, as often happens, the surgeon cannot decide 
between intra- and extraperitoneal rupture—an incision should be made 
in the median line, extending from an inch below to two inches above 
the upper border of the symphysis. The peritoneum is not opened, but 
an opportunity is afforded to search carefully for an extraperitoneal 
rupture. If none such be found, the incision is prolonged upward 
sufficiently to enable the surgeon to open the peritoneum and examine 
the portion of the bladder covered thereby. 
If an extraperitoneal rupture be found, the surgeon has a choice of 
three methods of treatment, exactly as in the operation of suprapubic 
cystotomy : (1) to suture the bladder wound (excluding the mucous 
membrane) and leave a drain down to the bladder; (2) to leave the 
bladder rent open, inserting a drainage-tube therein; and (3) to suture 
the torn edges of the bladder to the skin. The choice will be deter- 
mined partly by the location of the tear, but chiefly by the condition of 
the urine. If this be aseptic, the first method should be employed; if, 
on the other hand, the patient already has a septic cystitis, the second 
plan will be better. 
If the rent in the bladder-wall be wholly intraperitoneal, the wound 
should be carefully sutured throughout its entire extent. When the 
rent is partly within and partly without the peritoneum, it should be 
completely sutured, and the bladder then attached to the abdominal wall 
for extra security against leakage of urine. 
Sutures of the bladder should be of fine silk with the ends cut short; they 
should be placed not more than a quarter of an inch apart, should extend beyond 
each end of the wound, and should not include the mucous coat; the mattress 
suture should be used. After the seam is finished it should be tested by moderate 
distention of the bladder with water. Sutured wounds of the peritoneal surfaces 
heal very rapidly, those beyond the peritoneum less quickly and surely. 
Kidney.—Injuries of the kidney are, for obvious reasons, always 
grave lesions : the extreme vascularity of the organ itself, its proximity 
to large blood-vessels and to the peritoneum, its vital importance to the 
organism, account for the heavy mortality accompanying serious injuries 
to its substance. Hemorrhage, sepsis, and peritonitis from the escape 
of urine have each resulted in many deaths. Clinically, we may divide 
injuries to the kidney into open and subcutaneous lesions, the former 
made by penetrating objects, the latter by falls, blows, and severe com- 
pression. 
The symptoms of the open injuries, aside from the extent of the 
wound, are shock, nausea, and hemorrhage, the latter from the wound 
and through the bladder; pain radiating to the testicles is sometimes 
observed. The escape of blood does not always measure the hemor- 
rhage, however, as this may occur chiefly into the torn peritoneum or 
retroperitoneal connective tissue. Blood-clots may plug the ureter and 
cause colicky pain, as well as retraction of the corresponding testicle; 
in the bladder clots cause vesical tenesmus and pain. Permanent block- 
ing of the ureter causes either urinary fistula or atrophy of the kidney. 
The escape of urine into the perirenal tissues usually indicates a lacera- INJURIES. 
467 
tion of the kidney pelvis; it may be followed by extensive suppuration 
and sloughing. 
The symptoms of subcutaneous rupture and laceration of the kidney are 
identical, except that the signs of severe hemorrhage and suppuration are neces- 
sarily more obscure; indeed, the admixture of blood with the urine may be first 
observed several days after the injury. Fluctuating swellings in the kidney region 
may gradually appear, composed either of blood (hsematoma) or of urine, usually 
the former. Extensive ecchymoses, extending even to the scrotum, have been 
observed. . 
The treatment of injuries to the kidney seeks to arrest hemorrhage 
and to prevent stagnation of escaped urine. The measures required to 
secure these ends vary with the extent and locality of the injury; and 
these, unfortunately, the surgeon is often unable to determine without 
Fig. 210. 
Gunshot wound of kidney, necessitating nephrectomy (Richardson). 
manual examination of the kidney. Hemorrhage constitutes, of course, 
the more urgent demand for immediate interference ; in cases where this 
is apparently slight no operative measures may be at first required, 
though the result may sometimes be death from concealed hemorrhage. 
If in a few days evidence of urinary infiltration becomes apparent, suit- 
able incisions and drainage should be made. 
In many cases severe hemorrhage compels immediate exposure of the 
kidney through a lumbar incision; and this would probably be the wise 
course in all cases of undoubted laceration of the organ. Bleeding from 
the kidney substance can be promptly checked by sutures of the kidney 
and of its fibrous capsules; hemorrhage from the large vessels compels 
ligature of the same, usually with removal of the kidney. Any lace- 
rations of the kidney pelvis or ureter should be sutured with silk and 468 
GENITO- URINAll Y S URGER Y. 
the vicinity thereof drained. Sometimes a septic cystitis is caused by 
decomposing blood-clots in the bladder, compelling drainage of this 
organ. 
Wounds of the kidney substance heal rapidly : even if so extensive 
as to involve much of the organ, the opposite• kidney will hypertrophy 
to any required extent. Wounds of the kidney pelvis heal more slowly, 
often requiring months, but the fistula usually closes ultimately without 
interference. 
Infections. 
An infection is a bacterial invasion of a living tissue—a growth of 
one or more species of bacteria in the tissue, with the local and general 
disease caused by the diffusion of injurious bacterial products. 
The genito-urinary tract of the male frequently exhibits a primary 
infection by the following bacteria : 
1. The gonococcus ; 
2. The as yet undiscovered agent that produces syphilis ; 
3. The tubercle bacillus ; 
4. The various bacterial species that cause suppuration—a dozen 
or more in number—collectively termed the pyogenic bacteria. 
1 and 2. Gonorrhoea and Syphilis.—The gonococcus, with the atten- 
dant pus-bacteria, producing the mixed infection known as gonorrhoea ; 
it and the syphilitic infection are discussed in Chapters X. and XI., Vol. I. 
3. Tuberculosis.—The growth of the tubercle bacillus of Koch in 
various tissues of the genito-urinary organs is a frequent and most im- 
portant primary infection of these organs, aside from the numerous cases 
in which the primary disease occurs in the lungs with secondary 
infection of the urinary passages. 
By primary tuberculosis is meant the earliest perceptible tuberculous focus: 
it is of course always possible that infection of the bronchial nodes or other inac- 
cessible parts may have preceded the outbreak of the disease in the genito-urinary 
tract. 
Sites of Infection.—Primary genito-urinary tuberculosis usually first appears in 
the epididymis and the ejaculatory duct, less commonly in the kidney, yet it rarely 
remains long limited to these organs, the prostate and seminal vesicle soon becom- 
ing infected. In a very few instances tuberculous ulcers of the skin of the penis 
seem to have been the first manifestation (it is possible that some sores called 
chancres, and not followed by syphilis, have been tubercular ulcers). 
Avenues of Infection.—The possibility must be admitted that the foetus at birth 
may contain tubercle bacilli, yet opportunity for infection after birth is so general 
that this seems the more plausible explanation. It is probable that infection of 
the genito-urinary organs is practically always by one route—the blood-current— 
whereby the bacilli are brought from lungs, intestines, or old foci in the cervical 
and bronchial nodes. 
The idea that intercourse with a woman suffering from tuberculosis of the pel- 
vic organs can cause the ascent of tubercle bacilli along the male urethra to the 
prostate is fanciful and utterly without proof. That such intercourse may inocu- 
late the skin of the male genitals, with subsequent lymphatic transfer to the pelvic 
organs, is demonstrated, and it is probable that the urethra and prostate have been 
occasionally infected by urethral instruments. Yet since a large percentage of 
genito-urinary tuberculosis occurs in youths who have never had intercourse nor 
been subjects of urethral instrumentation, we must consider the blood-current the 
usual avenue of infection. 
Age of Patients.—The liability of the genito-urinary tract to active tuberculosis 
begins with puberty, and is especially manifest during the succeeding ten or fifteen INFECTIONS. 
469 
years. While, therefore, tuberculous nodules have been demonstrated in the epi- 
didymis of children prior to puberty, and while tuberculosis has been observed in 
the genital organs of elderly men, nearly all cases of genito-urinary tuberculosis first 
attract attention between the ages of fifteen and thirty-five. Yet since the disease 
rarely causes pain until the mucous surface of prostate or bladder is invaded, it may 
exist for years in the other organs without causing the patient to seek medical advice. 
Predisposing Influences.—Among the factors which favor the lodgement of the 
tubercle bacilli are—that ill-defined vice of nutrition that we term hereditary pre- 
disposition, injury, and possibly gonorrhoea. Yet genito-urinary tuberculosis is 
frequently found in robust, athletic subjects, in whose history none of these pre- 
disposing factors can be traced; and this is a fact of importance, because we are 
apt to think that a patient cannot be tuberculous without being cachectic. 
The symptoms and treatment will be considered under the diseases 
of the respective organs. 
4. Sepsis.—The urinary channels are peculiarly exposed to the 
entrance of bacteria by way of the blood-current, the urethra, and the 
rectum. Yet it seems that septic infection of the normal urinary tract 
does not occur—in other words, that suppuration in this tract is always 
preceded by some impairment of nutrition whereby the natural tissue 
resistance is depressed. Many examinations have demonstrated that the 
normal urinary tract from kidney to prostate is absolutely sterile, and, 
though the normal urethral surface is known to harbor many pus- 
bacteria, yet they fail to enter its tissues until these have been disturbed 
by some other agency. Hence cystitis, urethritis, and pyelitis are terms 
expressing results rather than primary conditions. 
When the natural vitality of tissues is lowered by any agency, such 
as the growth of the gonococcus or tubercle bacillus, the stagnation of 
urine in the bladder caused by a tight stricture or prostatic enlargement, 
the pus-bacteria—which easily gain access by one of the routes men- 
tioned—may infect a part or the whole of the urinary tract. 
Examination of Patients.—The information elicited is subjective, 
given by the patient, and objective, ascertained by the examiner. The 
patient should be questioned as to the frequency of urination by night 
as well as by day ; as to the locality and frequency of pain in urination ; 
whether micturition is urgent; whether there is involuntary escape of 
urine; and whether this fluid has been observed to contain blood or 
pus. The age and occupation of the patient, the duration of his ail- 
ment, antecedent diseases (especially gonorrhoea, syphilis, sexual excesses, 
and dyspepsia) should be the subject of inquiry. 
The information given by the patient may or may not indicate the seat and 
nature of the trouble; the examiner should learn to depend upon his own investi- 
gation rather than upon the patient’s statements. The instruments required for 
such examination are lingers, eyes, bulbous sounds (or urethrometer), conical 
sounds, endoscope, cystoscope, microscope, and thermometer. 
In every case except recent gonorrhoea a complete examination should be made; 
the temperature should be taken ; the heart and blood-vessels examined; the exter- 
nal genitals, particularly the prepuce and meatus, inspected; the testicle, epidid- 
ymis, and spermatic cord felt between thumb and finger; the suprapubic and renal 
regions percussed and palpated; the posterior surface of prostate and bladder 
explored by the finger in the rectum. The last-named measure is an extremely 
important though often-neglected means of diagnosis: the examining finger should 
carefully note the size, consistence, smoothness, and symmetry of the prostate, and 
whether the normal notch between the upper ends of the lateral halves is distinct; 
the size, consistence, and tenderness of the seminal vesicles and ampullae should 
also be observed. Pressure with the other hand above the symphysis brings these 
organs nearer to the examining finger. 470 
GENITO-URINARY SURGERY. 
The patient is required to urinate into three small glasses—say a half 
ounce each into the first and second; then the examiner introduces the 
finger into the rectum and gently presses the prostate and seminal tubes, 
after which the patient passes the remainder of his urine into the third 
glass. The first of these glasses contains the washings of the urethra, 
the second a fair specimen of the bladder urine, and the third the products 
of the prostate and seminal tubes. 
In many cases—as of tuberculosis, chronic gonorrhoea of the prostate and 
appendages, malignant disease of the prostate—the diagnosis is established by the 
measures already mentioned. Yet unless there is some special objection the inter- 
nal examination of the urinary passages should follow. First, the calibre of the 
urethra as far as the bulb is examined by means of bulbous sounds or the urethrom- 
eter, and strictures carefully noted; then a metallic sound of large size and short 
beak (15 to 17 of the English scale, unless strictures compel a smaller size) is passed 
carefully through the deep urethra. 
To examine the cavity of the bladder this organ should be washed out and 
then distended with about five ounces of warm sterilized water or very weak anti- 
septic solution ; a short-beaked sound can then be introduced, the handle depressed 
below the level of the symphysis, and the instrument rotated on its axis in the 
search for a stone. If the cystoscope be used, the sound can be dispensed with, as 
the former instrument is a good stone-searcher: by means of the cystoscope the 
surgeon inspects not only the interior of the bladder, but also the orifice of the 
ureters, noting the frequency of the ureteral discharges into the bladder, as well as 
the appearance of pus or blood from these orifices. Finally, the endoscope may 
sometimes be required for the determination of the condition of the urethral 
mucous membrane. 
The urine obtained should always be submitted to the usual chemical tests, and 
when necessary examined with a microscope for pus, blood, epithelium, crystals, 
and the pus for tubercle bacilli or gonococci. 
In special cases it is best to obtain the washings of the anterior urethra by 
introducing a soft catheter to the bulb, and irrigating this channel before the 
patient urinates; after which the urine may be passed into three glasses as above 
described. 
Diseases op the Penis and Urethra. 
Penis.—Aside from injuries and malformations (already described), 
diseases of the penis are commonly associated with, and often proceed 
from, diseases of the urethra. The skin of the penis is the seat of vari- 
ous innocent affections which, because of the extreme sensitiveness of 
the patient to any abnormality of the genitals, often occasion needless 
alarm. The most frequent of these are herpes, warts, and scabies. 
Herpes is a not infrequent disease, the vesicles appearing on the 
inner surface of the prepuce and in the furrow behind the gland. At 
times it is evidently favored by obvious conditions, such as a tight pre- 
puce, lack of cleanliness, or a gleety discharge; in other cases no local 
cause can be detected, and it is assumed that the disease is due to gouty 
or neurotic influence ; in these cases it is often recurrent. The vesicles 
usually follow the same course as herpes elsewhere ; sometimes, however, 
they ulcerate obstinately. 
It is always important and sometimes difficult to distinguish herpes from vene- 
real sores; the difficulty arises in cases of obstinate ulcerating herpes. Indeed, it 
may happen that a genuine chancre or chancroid develops on the site of the herpetic 
blister, the patient having unfortunately exposed himself during the course of the 
herpes and having received the infection at that spot. DISEASES OF THE PENIS AND URETHRA. 
471 
The treatment of herpes is local and general, the former consisting 
in the removal of the obvious local causes already mentioned, and in the 
application of liquid tliyol or oleate of zinc on a thin layer of cotton 
inserted between prepuce and glans. The general treatment attempts 
to correct the gouty, neurotic, or other unhealthy tendencies of the patient. 
In cases of persistently recurrent herpes circumcision is often needful to 
a cure. 
Warts (pointed condylomata) of the prepuce and glans are often 
developed during or after gonorrhoea, and sometimes without apparent 
cause. They may be snipped off with scissors and their bases cauterized 
with nitrate of silver ; a less objectionable but longer method is the daily 
application of liquor arsenicalis or of acetic acid. Under its use the 
wart shrivels, dies, and drops off 
Scabies appears on the penis and scrotum very early after its acqui- 
sition on the hands ; it needs only to be recognized in order to be success- 
fully treated with suphur or naphthol. 
Cavernitis, acute and chronic inflammation of a corpus cavernosum, 
may result from gonorrhoea, mechanical injury to the penis or urethra, 
or syphilis. The chronic cases are not uncommon, attracting the patient’s 
attention by localized tenderness and hardness of the penis and especially 
by the curvature of the organ when erect. 
The treatment consists of local inunctions of mercurial ointment, 
with massage, and of the iodides internally if the patient be syphilitic. 
Such treatment commonly secures a decided improvement in the symp- 
toms in the course of a few weeks. 
Gummata of the penis occur either in the cavernous bodies or in the 
furrow between them. Distinct nodules in this locality should always 
arouse the suspicion of syphilis and lead to specific treatment. 
Epithelioma of the penis usually begins as a warty growth at or near 
the sulcus, sometimes on the body of the organ. It occasions but little 
pain until ulceration occurs; local extension and lymphatic infection 
are slow. It must be carefully distinguished from ulcerating gumma, 
which is far more common and has often been erroneously called cancer; 
syphilitic treatment will soon decide a doubtful diagnosis. 
The treatment should consist of amputation of the penis at least 
a half inch behind the nearest point of infiltration; less radical meas- 
ures, such as excision of the growth, usually fail and waste valuable 
time. Careful examination of the inguinal nodes and thorough removal 
of all, if any seem infected, should be made at the same time. 
In amputation through the body of the penis the skin and urethra should be 
cut a half inch longer than the corpora cavernosa, the urethra split front and 
back, and its edge stitched to the cut edges of the skin. If the cancer extends 
close to the symphysis, the entire penis must be removed, the corpora cavernosa 
being dissected from the pubic bones; in such cases the scrotum and testicles 
should also be ablated. Care must be taken to preserve the membranous urethra, 
which is the chief sphincter of the bladder, and the cut edges of the mucous 
membrane should be united with those of the skin. 
Urethra.—The diseases of the urethra not yet described are chiefly 
ulcers, vegetations (polyps), chancres, and strictures. Cancer of the 
urethra is exceedingly rare, only about a dozen cases having been as yet 
demonstrated. 
Ulcers of the urethra occasionally persist after gonorrhoea, and may 472 
GENITO-URINARY SURGERY. 
be responsible for a slight gleet. They can be seen through the endo- 
scope, and touched with copper sulphate or other astringent. Thorough 
stretching of the urethra is usually necessary to cause the absorption 
of the inflammatory exudate surrounding the ulcer; indeed, there is no 
doubt that this alone has often secured healing. 
Vegetations and polyps are sometimes discovered in connection with a gleet; 
they can be detected and treated only through the endoscope. The larger ones 
(polyps) have been snared or torn off', the smaller ones withered by careful appli- 
cation of the liquor arsenicalis or acetic acid. 
Chancres occur in the first half inch of the urethra, doubtless far 
more commonly than is generally supposed. They cause a slight puru- 
lent discharge and some smarting on urination—symptoms which are 
assumed to indicate a mild gonorrhoea. The surgeon should make a 
practice of separating the lips of the meatus and inspecting the urethral 
surfaces in every case of mild urethritis; endoscopic examination is 
more complete. 
Strictures of the urethra are portions of the canal whose dilatability 
is less then normal; they have usually been classified as spasmodic, 
inflammatory, and organic. 
The term spasmodic stricture is applied to a narrowing of the channel 
due to a supposed spasmodic contraction of the muscular fibres encircling 
the urethra. 
While such spasm is doubtless possible—at least in the membranous portion— 
the obstruction often met at the bulbo-membranous junction and ascribed to spasm 
is frequently due to unskilful handling of the instrument; this is not made to 
follow the natural curve of the urethra, and hence strikes against the firm trian- 
gular ligament just behind the bulb. The more skilful in catheterism the surgeon 
becomes, the less frequently he discovers “spasmodic stricture.” 
The term inflammatory stricture designates the swelling of the tissues 
during gonorrhoea, and is properly becoming obsolete. 
Organic stricture—the only persistent and properly styled narrowing 
of the urethra—means a diminution of the normal distensibility of this 
canal by an overgrowth of the submucous connective tissue, which 
may be either congenital or acquired as the result of any inflammatory 
process, lacerations by instruments or by fragments of calculus, blows 
and crushing injuries, and severe urethritis. 
According to their etiology, organic strictures are usually classified 
as traumatic and gonorrhoeal: this division has been perpetuated because 
it was formerly supposed that all strictures not traumatic resulted from 
gonorrhoea. 
It is now known that many strictures exist in men who have never had gon- 
orrhoea, but who, having never sought advice for urinary troubles, were formerly 
not examined for stricture; and it is reasonable to believe that many strictures 
which are detected only when the patient comes to be treated for gleet were pres- 
ent prior to that disease. It is certain that strictures of the first half of the ure- 
thra are often found in men who have never had gonorrhoea; some of them, at 
least, are congenital, due to the incomplete removal of the connective-tissue par- 
tition which in early foetal development separates the penile from the glandular 
urethra. 
A more rational—and clinically important—classification of strictures 
is into traumatic and non-traumatic, the latter class including congenital 
and gonorrhoeal strictures. 473 
STRICTURE OF THE URETHRA. 
Organic strictures may be present at any time of life, but are most 
frequently detected between the ages of twenty and forty-five. In the 
last decades of life strictures become far less troublesome than in middle 
life, possibly from the proneness of the fibrous tissue to undergo fatty 
degeneration. For anatomical reasons women suffer less frequently 
from urethral strictures than do men. 
When arising from gonorrhoea or other urethral inflammation a considerable 
time—one to several years—elapses between the occurrence of the inflammatory 
process and the consolidation of the exudate into firm connective tissue, and its 
contraction to a degree which materially impedes the exit of urine; hence many 
strictures exist for years before the patient becomes aware that something serious 
ails the urethra. Traumatic stricture, on the other hand, due to mechanical 
injury, contracts very rapidly—in a few weeks or months—to such a degree as to 
require treatment. 
The location of a stricture may be anywhere from the meatus to the 
membrano-prostatic junction; strictures of the prostatic urethra are 
practically unknown. Probably the two most frequent sites of stricture 
are the bulbo-membranous and the glandular portions. Several stric- 
tures may coexist in different portions of the same urethra. 
The calibre of a stricture means the distensibility of the urethra at 
the strictured point, and is expressed in terms of the French or English 
catheter scale. 
Otis proved that the distensibility of the normal urethra was much greater 
than had formerly been supposed—that in the average man it ranges from 30 to 
34 of the French scale; and he was inclined to attach much pathological import- 
ance to slight narrowings of the canal below this size. For several years his 
disciples asciibed many disorders of the genito-urinary tract to these alleged 
“strictures of large calibre,” and they attempted to cure such troubles by a rather 
generous practice of internal urethrotomy. Later experience has shown that the 
distensibility of the normal urethra varies decidedly in different parts of this 
canal; that many of the so-called strictures of large calibre are normal structures; 
and that their division fails to cure anything. 
The term “ stricture ” should be applied only to an overgrowth of 
submucous connective tissue which causes an unnatural rigidity of the 
urethral wall. While in certain individual cases opinions might differ 
as to the propriety of applying the term “ stricture ” to a given urethral 
narrowing, yet there is general agreement that slight narrowings of 
the urethra may be ignored as pathological entities; the term “ stric- 
tures of large calibre ” may be applied to narrowings of the canal which 
permit a No. 20 French instrument to pass. 
Effects on Urethra.—At the strictured point the urethra may present 
but slight changes from the normal condition ; behind the stricture, 
however, marked changes ensue, which become more pronounced as the 
calibre of the strictured part decreases. These changes are largely due 
to the pressure of the urine, which is arrested by the stricture and dis- 
tends the urethra behind it; moreover, a few drops of urine are apt to 
remain and decompose behind the stricture. The mucous membrane 
becomes thinned, atrophied, and, though deeply congested, its epithelium 
becomes eroded; superficial and then deeper ulceration ensues, and 
finally the urine escapes into the surrounding tissues, making peri-ure- 
thral abscesses and fistula;. 
The course of a stricture is constantly toward contraction, at least 
until the patient becomes fifty or more years old, when fatty degenera- 474 
GENITO- URINA 11Y S URGER Y. 
tion is apt to ensue; the connective-tissue mass becomes firmer and 
harder, resembling cicatrix. The body of this cicatricial tissue is apt 
to be on the floor rather than the roof of the urethra, so that the opening 
through a stricture is frequently on the upper side of the canal. 
Traumatic strictures differ anatomically from the lion-traumatic only 
in degree; the mass of new connective tissue is larger, its contracting 
tendency greater, and hence the difficulty in maintaining the patency 
of the urethral canal greater. Traumatic strictures are as a class very 
obstinate and difficult to treat. 
Symptoms.—The morbid phenomena produced by urethral strictures 
vary in details according to the location and extent of the contraction, 
but two very frequent results require special mention : 
(a) Effects upon Micturition.—These are especially three—(1) in- 
creased frequency of the act (by night as well as by day); (2) diminu- 
tion in size and force of the stream ; and (3) dribbling at the end of 
urination. 
These obvious results of a decided narrowing of the channel are far more pro- 
nounced when the stricture is situated in the bul bo-membranous region than when 
it is in the anterior portion. Various other phenomena are often observed, such 
as a muco-purulent discharge from the meatus, a scattering of the urinary stream, 
pain during seminal omission, dribbling of semen after subsidence of erection, 
imperfect erection, and premature ejaculation. 
(b) Prolongation of a, Gleet.—One of the frequent causes for the 
persistence of a gleety discharge, in spite of various injections and 
internal medications, is the morbid condition of the strictured urethral 
wall. 
At and behind the narrowed point the epithelial lining as well as the sub- 
mucous tissue is in a state of chronic inflammation, with catarrhal discharge, and 
the urethra in this region fails to contract and empty the urine after each micturi- 
tion; hence more or less urine is retained in contact with the surface back of the 
stricture, keeping up a constant irritation. 
Diagnosis.—In every case of gleet or of disordered micturition 
examination of the distensibility of the urethra should be made; indeed, 
such examination should be a routine part of the investigation of almost 
every case of chronic urinary or genital disorder. Narrowing of the 
urethral canal may be detected by bulbous sounds (bougies a bou/e) when 
the meatus is sufficiently large to permit their introduction. When the 
meatus is abnormally small (less than 22 French) the surgeon must 
either enlarge this opening by incising its lower angle or use a specially 
constructed dilating bulb, called the urethrometer, which can be intro- 
duced closed through the narrow meatus and expanded within the canal. 
For reasons previously mentioned division of the meatus should be in 
general avoided. (See article Gleet, Vol. I. page 225.) 
The bulb, Well oiled, is introduced into the freshly irrigated urethra; if it pass 
freely, a larger one is used; and finally a 30 or 32 French is introduced if the 
smaller instruments have failed to detect any narrow point. These bulbs should 
not be passed farther than the bulbous urethra; the remainder of the canal is 
examined by the ordinary conical sounds. If the urethrometer is used, it is intro- 
duced closed to the bulb of the urethra; the expanding portion of the instrument 
is then dilated to 30 or 32 French, and gently drawn toward the meatus ; if obstruc- 
tion is met, the bulb of the instrument is reduced until it passes the obstruction, 
and then again dilated and further withdrawn. By these instruments the location 
and extent of urethral contractions can be determined. STRICTURE OF THE URETHRA; URETHROTOMY. 
475 
Treatment.—The restoration of the urethral distensibility is of 
course the object of treatment; and it should be understood that by all 
methods heretofore employed such restoration is usually imperfect and 
temporary. While by treatment the symptoms produced by stricture 
can usually be abolished, yet an anatomical cure is probably unknown; 
hence it follows that a recurrence of the contraction and of the symptoms 
produced by it are frequent. A young patient who has a stricture should 
be informed that even after thorough dilatation the stricture is apt to recur 
in a few years and need a repetition of the treatment, and that such recur- 
rences will probably continue until he has passed the age of fifty or fifty- 
five years. 
There are two principal methods of treatment of urethral stricture— 
gradual dilatation and incision (urethrotomy); and two subordinate 
methods of only limited application—electrolysis and massage. 
Gradual Dilatation.—This is the ideal treatment; it is successful in 
most cases of non-traumatic stricture, and should be regularly employed ; 
in comparatively few cases, to be presently mentioned, it fails. 
The value of gradual dilatation consists not in the direct spreading of the narrow 
portion, but in the fact that this stretching is followed by a pronounced congestion 
and exudation into the stretched portion, whose resolution includes the absorption 
of some of the connective tissue constituting the stricture. The repetition of this 
process every three or four days by the introduction of sounds of gradually increas- 
ing size causes ultimately a more or less complete removal of the strictured tissue. 
Urethrotomy was formerly much employed, but is now generally 
reserved for cases in which dilatation is ineffectual, because of the 
extreme hardness, extent, and bloodlessness of the stricture tissue. 
There are three classes of strictures in which urethrotomy must often 
be done : (1) traumatic strictures of the perineal urethra; (2) strictures 
of the glandular urethra—that is, within a half inch of the meatus, for 
experience shows that dilatation is often ineffectual in these cases; and 
(3) cases in which extravasation of urine has occurred, compelling incis- 
ions for drainage. While, therefore, urethrotomy is required in a 
majority of cases of stricture, it should be reserved as the treatment of 
necessity : the method of choice should be always gradual dilatation. 
Internal urethrotomy—incisions by an instrument introduced within 
the urethra—is not without danger, the mortality being at least 2 per 
cent.; if the blade perforates the basement membrane, there is a great 
chance of severe hemorrhage and of urinary infiltration, followed by 
local abscess and even by general septic infection; after recovery the 
penis may exhibit a pronounced curvature when erect, due to local 
destruction of the cavernous tissue. These unpleasant complications 
are especially probable if the cut be made on the roof of the urethra. 
These objections do not obtain in cutting strictures within a half inch of the 
meatus, the only locality in which internal urethrotomy is advisable; for here the 
incision made on the floor of the urethra should be extended through the meatus, 
thus affording perfect drainage and eliminating the danger of abscess and of septic 
infection ; nor can the hemorrhage be serious from such a cut. 
It must be remembered that the entrance of morbid urine into the tissues may 
be followed by acute intoxication, severe and even fatal; this may occur within 
twenty-four hours, before suppuration has developed, and is due either to substances 
preformed in the urine or to a peculiarly acute bacterial infection. While less 
common than ordinary septic infection, it does sometimes follow internal urethrot- 
omy, and constitutes an additional warning against this operation. 476 
GENITO- URINAR Y SURGER Y. 
If an old stricture of the penile urethra should be found undilatable, 
a combined operation—internal urethrotomy and external perineal ure- 
throtomy—should be made: the urine is thus prevented from entering the 
wound in the penile urethra, because drained out through the perineal 
tube, and the dangers of urinary infection are thus avoided. 
External Urethrotomy.—In the deep urethra internal urethrotomy 
should never be made, for extravasation of urine is very probable and 
very serious, the firm fascia of the triangular ligament confining the 
septic material. When it becomes necessary to cut a stricture of the 
deep urethra (many traumatic strictures cannot be dilated without severe 
laceration) the cut should always be made from the outside—an external 
urethrotomy or perineal section. After complete division of the stricture, 
as shown by the passage of a large sound from the meatus, a drainage- 
tube is carried into the bladder and permitted to remain from six to ten 
days. 
Treatment is continued by gradual dilatation with conical instruments, the nar- 
row point of which is passed through the strictured canal, after which gentle pressure 
forces the tapering portion into the gradually widened channel The instruments 
may be elastic (bougies) or metallic (sounds); the former are preferable for long or 
multiple strictures, though their surfaces are rougher than the polished metal. 
In general, straight sounds with conical tips are best for the penile urethra, and 
curved sounds for the deeper portion. The calibre of the stricture having been 
ascertained by the bulbous sounds, the surgeon selects a conical sound whose point 
is smaller and shaft about two (French) sizes larger than this calibre. The patient 
being in the recumbent position (no urethral instrumentation should be performed 
in any other position), the urethra having been well irrigated and the instrument 
lubricated with clean vaseline, the sound is gently introduced until the conical 
extremity is felt to be through the stricture, the instrument being “ engaged ” 
therein ; the penis meanwhile is stretched along the sound so as to obliterate 
transverse folds. Steady but gentle pressure for a few minutes or less will force 
the shaft through. The judgment of the surgeon must determine the amount of 
force that can be used ; in general, a gentle pressure for a longer time is far supe- 
rior to severe pressure for a few seconds. The instrument is allowed to remain in 
the stricture for a quarter or half minute, than gently withdrawn. Three or four 
days later a sound one or two French sizes larger is introduced in the same way: 
this will be facilitated if the surgeon first passes the sound used at the last sitting, 
and follows it in a few minutes with a larger size. The gradual dilatation should 
be continued at successive sittings, three or four days apart, until a 30 to 34 French 
(according to the size of the urethra) passes freely. 
During the first twelve or twenty-four hours following the passage of the 
sound there is often sufficient swelling of the strictured tissues to cause a notice- 
able diminution in the size and force of the stream; after this the flow of urine is 
decidedly better than before the use of the instrument. Care should be taken not 
to use much force, lest three unpleasant results follow': (1) sufficient laceration to 
cause annoying bleeding; (2) great soreness at the site of stricture for several 
days, often with purulent urethritis; and (3) chill and fever, one of the forms of 
“ urinary ” or “ urethral ” fever. It is true that chill and fever may follow' the 
gentlest instrumentation in the urethra, especially in the prostatic portion, but the 
chances for it are greatly increased by the forcible use of instruments. 
In two classes of cases special instruments and measures are required 
for the execution of gradual dilatation: these are cases of very tight and 
narrow stricture, and cases in which the meatus is unduly contracted. 
Tight and “Impermeable” Strictures.—In consequence of the patient’s 
neglect to seek assistance, the connective tissue constituting a stricture 
may have contracted so much as to almost occlude the urethral canal, 
permitting the passage of urine only in a very fine stream or even by 
drops. If the subject of such a stricture becomes chilled through TREATMENT OF URETHRAL STRICTURE. 
477 
exposure or indulges to excess in alcoholic drinking, he may suddenly 
find himself absolutely unable to void urine. Such strictures are usually 
amenable to gradual dilatation, provided an instrument can be made to 
pass the narrow portion ; this attempt must be made by filiform bougies. 
Formerly, such bougies were made of the same diameter throughout ; 
the later form, called the “ whip,” is far more useful: it is filiform for 
several inches of its length, and then gradually increases in size to 12 
or 15 of the French scale. 
When called upon to treat a tight stricture, impermeable to ordinary bougies, 
the surgeon should first—especially if there be a history of recent and sudden 
diminution of the stream due to oedem- 
atous swelling of the stricture—apply 
hot water freely to the penis and peri- 
neum, both externally by baths or 
fomentations, and internally by injec- 
tions. Then olive or castor oil is in- 
jected into the urethra and retained by 
closing the meatus; a filiform (or, bet- 
ter, a whip) bougie is gently introduced, 
the penis being drawn taut so as to 
obliterate transverse folds of the ure- 
thra. And now begins what is often a 
test of patience for both surgeon and 
patient: the filiform is gently advanced 
to the stricture and trials made to make 
its point find the minute opening in 
the same. Sometimes success is imme- 
diate ; more frequently repeated trials, 
continued for many minutes, are made 
before the instrument passes. Only 
gentle force should be employed, since 
undue violence may result in punctur- 
ing the urethra (a false passage) or in 
doubling the end of the filiform. If the 
ordinary filiform finally passes freely 
beyond the stricture, an effort should 
be made to pass a second along the side 
of the first, which should on no account 
be withdrawn, lest the surgeon have 
to repeat the tedious and painful per- 
formance. The filiform should be tied 
to the pubic hair or to a strip of adhe- 
sive plaster attached lengthwise to the 
penis, so that it cannot be forced out, 
and should be allowed to remain for 
twenty-four hours. At the end of this 
period the calibre of the stricture will 
be much increased, so that a small 
bougie can probably be passed without 
trouble and gradual dilatation begin. 
If the first instrument introduced be 
the whip bougie, it should be passed in 
until the expanded portion has been 
forced into or through the stricture, 
thus enlarging the contracted part at once to a size which will permit the passage 
of a small bougie. The patient should be warned that the urinary stream may 
become very small a few hours later, and instructed to sit in hot water if he should 
have difficulty in expelling the urine. 
Fig. 211. 
Rupture of urethra behind a tight stricture; death 
from rapid infection (Guyon and Bazy). 
If all efforts to pass the stricture fail, the surgeon may make a peri- 
neal urethrotomy, and, passing a small bougie into the urethra through 478 
GENITO-URINARY SURGERY. 
the incision, approach the stricture from behind. If the impermeable 
part happen to be the membranous urethra, he must either make a peri- 
neal section without a guide or a suprapubic cystotomy, and catheterize 
the urethra from the bladder. 
When the meatus is unduly small, strictures may be stretched by 
means of special instruments constructed on the principle of the dilating 
bulb, called urethral dilators. 
The barbarous and dangerous method of rupturing the stricture, 
formerly in vogue under the name of “ divulsion,” should never be 
employed under any circumstances. 
The treatment of stricture may be thus summarized: Gradual dilatation 
is the preferred and generally successful method; in tight strictures 
within half an inch of the meatus, and in tight strictures (especially 
traumatic) of the bulbo-membranous region, dilatation may fail. In this 
case internal urethrotomy on the urethral floor should be made in the 
former, and external perineal urethrotomy in the latter cases. Very 
tight strictures should be rapidly dilated by the whip bougies to 10 or 
12 French, after which gradual dilatation is performed. 
Urinary Fever. 
Instrumentation in the urethra and bladder is often followed by chills 
and high fever—phenomena variously termed urethral, catheter, or (best) 
urinary fever. These unpleasant symptoms most frequently follow 
lacerations of the mucous membrane, but can undoubtedly occur when 
no evidence of such laceration can be detected. The clinical course of 
urinary fever is variable : sometimes all morbid phenomena disappear in 
twenty-four hours; sometimes they last for several days; and in some 
cases—especially after the sudden evacuation of the chronically distended 
bladder of the patient with enlarged prostate—the fever assumes a 
typhoid aspect and continues until the patient’s death, a few weeks later. 
It is evident that the term urinary fever includes several distinct 
morbid conditions; these are— 
1. Intoxication, through lacerations of the mucous membrane, with 
poisonous substances in the urine; 
2. Infection of the blood-current, through such laceration, with septic 
bacteria ; 
3. Infection of the urinary passages—bladder, ureter, and kidney— 
with septic bacteria; a suppurative cysto-pyelitis; 
4. Acute congestion of the entire urinary tract—the so-called hyper- 
eemia ex vacuo—from the change in pressure by sudden withdrawal of 
the urine in cases of habitually distended bladders: this occurs when 
the catheter is first used in old men with prostatic enlargement, whose 
bladders have long been distended; and 
5. (Possibly) a reflex nervous action: this seems plausible, because 
the chill sometimes follows so quickly upon the instrumentation that 
any one of the foregoing conditions seems improbable. 
The avoidance of urinary fever should be attempted bv— 
1. Gentleness of all intra-urethral and intra-vesical manipulations, 
whereby the chance of lacerating the mucous membrane is diminished; 
2. Careful irrigation through a soft catheter of the anterior urethra, DISEASES OF THE PROSTATE ANI) APPENDAGES. 
479 
and (when septic infection of the bladder already exists) of the deep 
urethra and bladder before metal instruments are introduced ; 
3. In cases of chronically distended bladders, such as result from 
prostatic enlargement, the physician should be careful, if called upon to 
introduce the catheter for acute retention or other cause, never to evacu- 
ate the bladder completely at the first sitting: a portion only of the urine 
should be withdrawn, and the bladder gradually emptied by repeated 
catheterism during several days. 
Internal Urinary Antiseptics.—It was formerly supposed that the 
dangers of urinary infection could be much lessened or even abolished 
by the internal administration of antiseptic substances which are elimi- 
nated by the kidneys, such as salol and boric acid. This theoretical 
hope has not been fully realized in practice : though either of these sub- 
stances may be properly administered in five-grain doses every four 
hours, yet the surgeon should not place the least dependence upon the 
avoidance of infection thereby, nor be lulled into omitting any of the 
far more important local measures to the same end. 
DISEASES OF THE PROSTATE AND APPENDAGES. 
The prostate, its utricle, the dilated extremities of the vasa deferentm 
(called ampullae), and the seminal vesicles are, like the uterus and tubes 
of the female, enclosed in a thin fibrous sheath which I have called the 
broad ligament of the male. 
There is one notable difference, however, between male and female, in that the 
peritoneal covering of this sheath in the female is reflected from its top down its 
anterior surface before rising again on the posterior surface of the bladder, while 
in the male the peritoneum crosses directly from the top of the broad ligament to 
the bladder. There is, therefore, in the male no peritoneal pocket corresponding 
to Douglas’s pouch in the female, the sheath of the seminal tubes being adherent 
to the bladder; but the essential part of the broad ligament, the fibrous sheath, is 
found in both sexes alike. 
Recognition of this anatomical homology suggests a clinical analogy 
which experience shows to be well founded—namely, that infectious and 
suppurative processes extend from prostate to seminal tubes and the 
enclosing fibrous tissues, just as they are known to extend from uterus 
to the tubes and broad ligament. Hence we may properly speak of 
many diseases of the prostate and seminal tubes and vesicles collectively, 
designating these structures, for brevity’s sake, as the “ prostate and 
appendages.” 
Infections.—The most common of these is the gonorrhoeal (see Vol. 
I. Chap. XI.); indeed, this disease and its complications furnish prac- 
tically all examples of acute infection of these parts. 
The chronic infections are gonorrhoeal, septic, and tuberculous, of 
which the first named has been discussed in Volume. I. 
The chronic septic infections of the prostate and seminal tubes, when 
not gonorrhoeal, are caused by urethral instrumentation, caustic urethral 
injections, by extension from chronic urethritis due to tight stricture of 
the deep urethra, by extension from a cystitis, and probably some are 
caused, especially in middle-aged or elderly men, by prostatic calculi. 
They are favored by the chronic venous congestion of the pelvic organs 480 
GENITO- VEIN A BY SUE GEE Y. 
which is so common in elderly men as the result of constipation, alcohol- 
drinking, high living, and lack of exercise. 
The chronic tubercular infection of these organs is usually associated 
with tuberculosis in the epididymis, and, while often primary in the 
clinical sense, is perhaps usually derived from slumbering infections in 
cervical or bronchial nodes, etc. 
Clinically the septic infection is still usually termed chronic prosta- 
titis, and the tubercular infection, tuberculosis of these organs. 
Chronic prostatitis—which is really a chronic septic infection of 
the prostate and appendages—is due to one of the causes just mentioned, 
which renders the tissues a favorable soil for the growth of the pus- 
bacteria. It is often the sequel of an acute infection, but very com- 
monly also a chronic inflammation from the start. 
Symptoms.—There is dull pain in the perineum, suprapubic region, 
rectum, and sometimes in the glans penis, aggravated by jolting or 
sitting on upholstered chairs; pain in the sacral region (which the 
patient usually ascribes to his kidneys) is at times the most prominent 
feature. Urination is apt to be unduly frequent, and is sometimes fol- 
lowed by the escape of a viscid grayish or watery fluid (from the pros- 
tatic glands) which the patient commonly considers semen. Sometimes 
there is a continuous slight discharge of similar fluid from the meatus— 
the so-called “ prostatorrhoea.” Sexual desire is often decreased and 
the normal pleasurable sensation much diminished or even absent ; 
ejaculation is often premature, and erections may be feeble or may sub- 
side before emission occurs. The patient is often extremely despondent. 
This is really the condition of incipient impotence, and leads ulti- 
mately to practical loss of virility. Often the patient complains of the 
sexual symptoms only, while the others are elicited upon questioning. 
Examination with the fore finger (best enclosed in a rubber condom) discloses 
a sensitive and perhaps swollen condition of the prostate or seminal tubes, or of 
both, with more or less thickening of the connective-tissue envelope of these 
organs; in pronounced cases the recto-vesical space is a rather hard and sensitive 
mass in which the ampullae and vesicles are not distinctly perceptible. Gentle 
stroking or milking of these parts toward the anus is soon followed by the appear- 
ance at the meatus of considerable fluid containing a more or less distinct admix- 
ture of pus. 
Treatment.—This will naturally begin with the removal of the 
cause of the trouble when this is practicable; thus, a tight stricture 
must be dilated, a foreign body in the bladder removed, etc. The treat- 
ment directed especially to the prostate and appendages is the following : 
avoidance of constipation and of alcoholic and sexual excesses; the 
milking of the recto-vesical organ by gentle stroking with the finger- 
tip in the rectum toward the anus; this process is continued for three to 
five minutes and repeated every six or seven days unless vesical irrita- 
tion is induced, when the intervals are made longer. A large sound 
should be passed into the bladder once a week, its straight portion 
entering the prostate; deep injections of silver-nitrate solution (two 
ounces of a 1 : 3000 solution) once a week are helpful. The despond- 
ency of the patient should not be ignored; a cheerful prognosis and 
tonic remedies are useful. 
The local treatment will usually show early results in the removal 
of the sacral and suprapubic pain, improvement in urination, and the DISEASES OE THE PROSTATE AND APPENDAGES. 
481 
cessation of discharge; the restoration of the sexual functions generally 
requires a prolonged treatment. 
Enlargement (Hypertrophy) of the Prostate.—The familiar con- 
dition designated by each of these names includes two anatomical states : 
(1) a diffuse enlargement of the prostate, and (2) localized hypertrophies of 
its glandular and muscular tissues, which project into the bladder. 
The diffuse enlargement is certainly often and probably always the 
result of the process above described—chronic inflammation of the 
prostate—and it is always present in cases of so-called hypertrophy; 
the local hypertrophies may result from this inflammatory condition or 
may rank with tumor-formations in general. They are found in a large 
percentage in the cases of enlarged prostate, though their presence can- 
not usually be recognized until the bladder is opened, because they grow 
into the vesical cavity and cause no change in the rectal surface of the 
gland, which alone is accessible to the examining finger. They may 
Fig. 212. 
Intravesical enlargement of the prostate (Forgue). 
therefore be ignored, except in operative cases; our diagnosis and treat- 
ment before operation is that of diffuse enlargement. 
Prostatic enlargement is a disease of the second half of life, often 
beginning before the patient becomes fifty years old, but not usually 
causing him to seek a physician’s advice until after that period; indeed, 
the advanced cases of urinary derangement due to this cause are usually 
over sixty years of age. The enlargement of the prostate and the 
development of urinary symptoms are so gradual that the patient is apt 
to accustom himself to them as to other phenomena of advancing age, 
and when some pronounced symptom, such as complete retention of 
urine, leads him to summon medical aid, an advanced stage of the disease 
is found. Hence surgeons have been accustomed to meet the more 
advanced cases, and to think of prostatic hypertrophy as a condition 
of advanced age, while the disease really often begins in middle life, as 
above stated. 
Prostatic enlargement is serious—not directly, but because it inter- 482 
GENtTO- URINAR Y S URGER Y. 
feres with the exit of urine by causing (1) distortion of the prostatic 
urethra, which undergoes elongation, decrease in calibre, sometimes 
deviation in direction ; (2) elevation of the level at the vesieo-urethral 
orifice; and (3) obstruction to the return of blood to the bladder and 
chronic congestion of this organ. 
Following naturally upon the imperfect evacuation of the urine and 
the chronic congestion of the bladder conies a train of morbid condi- 
tions which begin with the bladder and ultimately extend throughout 
the entire urinary tract. These are (1) dilatation of the bladder, with 
increase of residual urine; (2) fibroid degeneration of the prostatic 
sphincter; (3) hypertrophy and degeneration of the vesical walls and 
depressions of mucous membrane (diverticula) between the muscular 
bands; (4) dilatation of ureters and renal pelvis, with stagnation of urine 
in them ; (5) congestion and catarrhal inflammation of the entire urinary 
tract, causing accumulation of its products in the bladder, tending to 
calculus-formation; (6) ammoniacal fermentation of urine, favored by, 
but not dependent on, the use of unclean catheters ; (7) septic infection of 
the congested urinary tract—“cysto-pyelonephritis ” and chronic uraemia ; 
(8) acute and fatal uraemia, provoked by various agencies, particularly 
the first use of the catheter. 
Symptoms.—Among the earliest are difficulty in starting the flow 
of urine, feebleness of the stream, and undue frequent calls to urinate, 
especially at night. During this state the patient often complains more 
of his digestion than of his urinary organs; he has loss of appetite, 
dryness of the mouth, and constipation. 
When catarrh of the bladder-neck begins the urinary symptoms 
become more prominent: the calls to urinate become more frequent, the 
normal sense of satisfaction is lacking, the urine becomes cloudy and 
deposits a white sediment. 
The incomplete evacuation of the bladder, causing chronic retention 
of a large quantity—a pint or even a quart—of urine, is apt to be 
followed by an involuntary escape of this fluid. This dribbling indi- 
cates not “ paralysis of the bladder,” but over-distention of the organ. 
Thus far, the patient may have been fairly comfortable and the nature of his 
disorder overlooked; but he is now apt to experience either of two events—a 
sudden aggravation of the hitherto mild cystitis or a complete retention of urine. 
Either may be provoked by prolonged chilling and wetting, especially of the feet, 
by excessive eating or drinking, or by constipation. In either of these events the 
patient usually becomes the subject of chronic cystitis, which exhibits varying 
degrees of severity, now remaining mild for weeks, again becoming so acute as to 
confine him to bed. 
Diagnosis.—A patient over fifty years of age whose history in- 
cludes these symptoms should be examined per rectum, and undue size 
of the prostate noticed. The presence of residual urine is then detected 
by the passage of a clean soft catheter immediately after the patient 
has urinated; a flow of urine (which should be stopped at two ounces) 
shows that the voluntary evacuation of the bladder is incomplete. 
The examiner must now exclude other morbid conditions which may give rise 
to the symptoms of cystitis, prominent among which are vesical calculus, prostatic 
cancer, and tuberculosis. Calculus can generally be recognized by the sound or 
cystoscope; cancer of the prostate, by the uneven, nodular hardness of the prostate, 
the enlargement of inguinal lymph-nodes, emaciation of the patient, and lisema- DISEASES OF THE PROSTATE AND APPENDAGES. 
483 
turia; tuberculosis, by the nodular thickening in the seminal vesicles and epi- 
didymis, as well as in the prostate. 
It should be remembered that the chronic retention of urine resulting from 
prostatic enlargement predisposes to the formation of vesical calculus, which is an 
exceedingly common—and often overlooked—sequence of this condition. 
Treatment is general and local. Personal hygiene is very import- 
ant, including good digestion, regular and easy defecation, warm cloth- 
ing, air and exercise, avoidance of cold and wet, of excess in eating or 
alcohol-drinking. The patient should drink three pints or more of pure 
water daily. 
Local treatment endeavors (1) to reduce the congestion and oedema of 
the prostatic region; (2) to promote the evacuation of the bladder ; and 
(3) to prevent or arrest septic infection of the urinary passages. 
(1) For the first object there are three principal means—the milking 
of the prostate by the finger in the rectum, previously described; the 
passage of a large sound once a week ; and the free use of hot water as 
baths, rectal enemata, and injections of the bladder. These latter can 
usually be made without a catheter, because the sphincters in such 
patients are not firmly contracted ; indeed, with a little perseverance the 
patient can learn to inject his own bladder from the meatus; this is most 
easily done in the semi-recumbent position. The amount of water should 
not be large enough to distend the bladder, but it should be hot (100° 
to 110° F.). 
(2) The contractile power of the bladder is greatly stimulated by 
these injections of hot water, probably because they reduce the oedema 
and venous congestion. In some cases, however, the patient must be 
taught to use the catheter. 
(3) Septic infection of the bladder, when not arrested by these means, 
must be combated by injections of silver nitrate (1 : 2000) or of mercury 
bichloride (1 : 20,000). 
Catheters should be Flexible and Clean.—The soft Nelaton catheter 
(velvet eye preferred) will usually enter the bladder; if it fail, the stitfer 
conde instrument of Mercier, commonly called prostatic catheter, gen- 
erally succeeds. Metallic instruments and those armed with a stylet can 
easily be made to lacerate the urethra, and are rarely needed except in 
cases of extreme hypertrophy. 
All instruments used should be aseptic. The soft and metal catheters 
can be sterilized by boiling; elastic instruments should be immersed in 
5 per cent, carbolic or similar solution. Catheters in frequent use should 
be kept in such solution. 
It is never amiss to warn the patient that flexible catheters are prone to disap- 
pear into the urethra; when one is inserted the outer end should be constantly- 
held. He should be also advised to discard a catheter when its surface becomes 
rough. 
It is important that the prostatic urethra as well as the bladder should be irri- 
gated—that is, before the solution is injected the catheter should be withdrawn 
until the eye has receded one to two inches from the bladder. The fluid then 
injected washes the prostatic urethra and passes onward into the bladder; the 
catheter can then be pushed back until the outward flow is re-established. Wash- 
ing of the bladder should always be made in this way, so as to wash the neck of 
the bladder—that is, the prostatic urethra. 
Internal medication has but little influence in improving the condition of the 
urine, yet there can be no objection to the proper use of the various demulcents— 
buchu, corn silk, etc. Salol, boric acid, and turpentine are also recommended, but 484 
GENITO-URINARY SURGERY. 
as the digestive organs of the prostatic are easily deranged, over-medication must 
be avoided. 
Complications.—These are (1) complete retention; (2)persistent cys- 
titis of great severity; (3) such distortion or narrowing of the prostatic 
urethra as renders catheterism extremely difficult or painful. 
Complete retention is a most serious event: when called to such a 
case the physician should observe three rules of great importance: (1) 
never use force nor lacerate the urethra—in other words, use flexible 
instruments; (2) observe .strict aseptic precautions as to instruments, etc.; 
(3) never empty the bladder completely at one sitting. 
The patient suffering from complete retention should have the rectum emptied by 
a hot-water injection, to be followed by a suppository containing a quarter grain of 
morphine. A hot sitz-bath or hot fomentations should be used for twenty or thirty 
minutes; the patient is then warmly covered in bed, the hips elevated above the 
shoulders. The anterior urethra is irrigated with hot water and injected with warm 
clean oil; a clean soft catheter (No. 10 or 12 English) is filled with the oil and 
introduced, the penis being drawn firmly forward. Steady pressure is often 
rewarded by a gush of urine; if this effort fail, an elastic prostatic catheter is 
next tried. If no false passage exist, the prostatic catheter will almost invaribly 
enter the bladder. If, however, the urethra be already lacerated, the difficulties 
of catheterism are enormously increased. If the softer instrument fail, a metal 
catheter of long curve and large diameter should next be used; but force must be 
scrupulously avoided, for no one can know the direction of the distorted and 
swollen prostatic urethra; forcible and blind catheterism results in false passages, 
hemorrhage, and a difficult situation. 
In rare cases suprapubic aspiration must be made, the needle enter- 
ing at right angles with the spine about an inch above the upper border 
of the symphysis. A half of the estimated contents of the bladder is 
withdrawn, hot fomentations again applied, and the patient left in bed 
for some hours; the relief of bladder tension and reduction of prostatic 
oedema thus secured often result in easy catheterism or even voluntary 
urination. But should retention persist, aspiration must be superseded 
by one of the methods of operative relief. 
Should the physician succeed in introducing the catheter, he must 
not evacuate the bladder completely at the first sitting; a third of the 
estimated quantity—say from six to ten ounces—may be withdrawn, 
and an ounce or two of some antiseptic solution injected. Some hours 
later a larger quantity may be withdrawn, and thus in the course of three 
or four days the bladder may be gradually emptied. Even with the 
greatest care some fever usually follows complete retention requiring the 
use of the catheter, yet the illness is kept at a minimum by the measures 
described. 
Persistent cystitis of high grade and difficult catheterism from pros- 
tatic distortion must be ultimately relieved by operative treatment. 
Operative Treatment.—Surgical aid may be furnished in one of three 
ways : 
(1) Drainage of the bladder, either bv perineal urethrotomy or supra- 
pubic cystotomy, or a combination of the two. The great improve- 
ments in suprapubic cystotomy (see section on “ Operations ”) render it 
the preferable method. 
Drainage of the bladder may be temporary or permanent. In many cases of 
comparatively recent origin the cystitis and inflammatory swelling entirely subside 
in two or three weeks, after which the tube may be removed and the wounds per- 
mitted to heal; the patient may then enjoy years of freedom from urinary discom- DISEASES OF THE PROSTATE AND APPENDAGES. 
485 
fort. In other cases, where the patient has long been unable to urinate without a 
catheter, the former troubles are apt soon to return ; in such cases it was formerly 
the custom to make the artificial opening permanent by having the patient wear a 
rubber or silver tube in the suprapubic opening, removing it daily for cleansing. 
Tn more recent times, however, the permanent fistula has fallen into disfavor, hav- 
ing been supplanted by the following operations. 
(2) Prostatectomy, by which is meant the removal of projecting por- 
tions of the prostate through the suprapubic wound and the restoration 
of a low level channel from bladder to urethra. The prostatic tumors, 
when pedicled, are removed by scissors, snare, or cautery; when im- 
bedded in the prostate they are enucleated, the mucous membrane cov- 
ering them being first freely incised, and an assistant’s finger in the rectum 
pressing the prostate firmly against the operator’s finger in the bladder. 
In this way large masses of hypertrophied prostatic tissue are easily 
enucleated. The hemorrhage is usually slight, and is controlled by hot 
water and packing with iodoform gauze. In every case of prostatec- 
tomy perineal urethrotomy should be made and the prostate thoroughly 
stretched ; any bar at the vesico-urethral orifice should be freely incised. 
(3) Castration.—The work of Hamm and White has led to the 
attempt to relieve sufferers from prostatic hypertrophy by the removal 
of both testicles, the plan having been suggested by the frequent atro- 
phy of uterine fibroids after the removal of both ovaries. As prostatic 
sufferers are frequently in advanced life, they sometimes consent to this 
mutilation in the hope of securing relief from the agonies of severe cys- 
titis and difficult catheterism. In a large percentage of the cases 
already reported more or less complete relief from cystitis has been 
secured, and in some the power of voluntary urination is said to have 
returned; in a smaller number more or less complete failure to secure 
any benefit whatever was the result. In some instances double castra- 
tion has been performed and recommended in cases where an undiscov- 
ered stone was subsequently found to be the cause of the trouble; for 
it is sometimes impossible to detect by the sound a calculus hidden in a 
pocket of the bladder. 
It is evident that this operation should be performed only after two premises 
have been established: first, that the patient’s cystitis is not due to vesical calculus, 
tumor, or any condition other than prostatic enlargement; and second, that the 
prospect of relief by simple temporary drainage of the bladder is not good. In 
other words, double castration should not be made until the bladder has been 
opened and explored by the finger. 
Ligature of the vas deferens on each side has been found in the few 
cases already tried to succeed as well as double castration. Since it is a 
slight operation, free from the objections—surgical and aesthetic—which 
may be urged against double castration, it should be substituted for the 
latter as a purely tentative procedure. 
To summarize: when surgical interference becomes necessary the 
best treatment is temporary drainage of the bladder with stretching of the 
prostatic urethra. If this exploration reveals such great distortion and 
overgrowth of the prostate as renders the cure by simple drainage doubt- 
ful, the surgeon must be prepared to make either a prostatectomy, a liga- 
tion of both vasa deferens, or a double castration. 
Tuberculosis of the prostate and appendages is a very frequent 
though often overlooked cause of the symptoms of cystitis; it is espe- 486 
GENITO-URINARY SURGERY. 
cially common between the ages of fifteen and thirty-five, and may 
occurs in otherwise healthy, robust subjects. 
The symptoms are those found in cystitis from other causes—fre- 
quency and pain in urination, as marked by night as by day, with pus 
and occasionally blood in the urine. Sometimes a slight muco-purulent 
discharge and swelling of the meatus give rise to a suspicion of gonor- 
rhoeal infection. 
The diagnosis can be established by digital examination of the epi- 
didymis and of the prostate and seminal vesicles, in each of which (at 
least on one side) nodular thickenings arc found. The discovery of 
tubercle bacilli in the urinary pus makes the diagnosis absolute. There 
is commonly a slight elevation of temperature. 
The treatment is medical and surgical. Operative measures should 
be limited to the evacuation of softened tuberculous foci; attempts at 
radical cure are futile both in theory and in practice. Medicinal treat- 
ment includes hygiene, dry air, sunshine, good food, and guaiacol: the 
drug should be given internally in doses of five, gradually increased to 
fifteen drops four times daily, in cream, milk, or wine, and it should be 
applied locally to the perineum, suprapubic space, and epididymis. To 
avoid irritation of the skin the guaiacol may be mixed with an equal 
volume of sweet oil or glycerin. 
Tumors of the prostate are papilloma, cyst, and cancer. Papil- 
lomata of the prostate have been occasionally detected and removed 
through the endoscope or by perineal urethrotomy. Cysts are commonly 
either dilatations of the prostatic utricle from occlusion of its orifice (as 
in new-born infants) or distended prostatic glands. Neither of these 
varieties is sufficiently common to require discussion. 
Cancer of the prostate—including carcinoma and sarcoma—is a not 
infrequent disease, occurring chiefly in patients under ten and over fifty 
years of age. About seven-eighths of the tumors are found on histologi- 
cal examination to be carcinoma, the remainder, sarcoma; the clinical 
distinction is often impossible and usually unimportant. 
Cancer of the prostate arises by extension from adjacent organs 
(rectum, bladder), by metastasis from cancer of a distant organ, and as 
a primary tumor. 
The symptoms of primary prostatic cancer are hcematuria, pain, and 
cystitis. The bleeding occurs without apparent provocation, and may 
for months be rarely seen ; in the later stages the hemorrhage often 
becomes profuse. Pain is felt in the perineum, rectum, and down the 
thighs, and is often increased by urination. Cystitis may not occur 
until the cancerous surface ulcerates. 
No one of these symptoms is invariably present. 
The diagnosis of cancer of the prostate is sometimes difficult and 
often neglected, because of the more frequent occurrence of the ordinary 
hypertrophy of the organ. 
Three of the most important and constant diagnostic signs are—(1) progressive 
emaciation and pallor ; (2) hard enlargement of lymph-nodes in the groins, with- 
in the pelvis, and in Scarpa’s triangle ; (3) irregular nodular enlargement of the 
prostate. The discovery of recognizable cancer-tissue in the urine or the inspec- 
tion of a malignant ulcer through the cystoscope is conclusive evidence. Prosta- 
tic cancer may be grafted upon senile hypertrophy, from which it must be care- 
fully distinguished. DISEASES OF THE BLADDER. 
487 
In children the fatal termination is reached in a few months; in elderly men 
the disease progresses less rapidly, lasting from one to five years. 
The treatment of prostatic cancer can be only palliative; for 
although the cancerous prostate has been extirpated ten times, yet the 
patients who survived the operation have all died of recurrence within 
a few months. The pain must be mitigated by morphine; cystitis and 
urinary retention require the treatment outlined for prostatic hyper- 
trophy ; and when other measures fail to relieve the vesical distress, a 
permanent suprapubic exit for the urine must be made. 
DISEASES OF THE BLADDER. 
Cystitis. 
Cystitis is a bacterial infection of the bladder: the pyogenic bacteria 
(especially the colon bacillus), the tubercle bacillus, and the gonococcus 
are the species most frequently concerned. 
Pyogenic bacteria are incapable of infecting a normal bladder: this 
has been amply proven by experiment, and is illustrated in the fact that 
unclean catheters and sounds are often introduced without causing 
cystitis. 
When, however, the nutrition of the bladder is impaired or its circulation 
seriously disturbed, as by a calculus, a tight urethral stricture, or prostatic enlarge- 
ment, then the pus-microbes are found growing in its walls and producing the 
inflammatory reaction that we call cystitis. These bacteria always have easy 
access to the bladder even when no instruments are used, for they may reach it 
Fig. 213. 
Internal appearance of bladder in some cases of inveterate cystitis; mucosa sacculated by columns 
of hypertrophied tissue (Launois). 
through the circulation, by extension from the urethra, or by penetration from the 
rectum. It has been shown that if the evacuation of a dog’s bladder be prevented 
by ligation of the urethra, and a slight abrasion of his anterior rectal wall be 
made, cystitis promptly occurs. The urine contains various pus-bacteria, most 
frequently the colon bacillus, which has invaded first the recto-vesical tissue and 
then the bladder-wall. 488 
GENITO-ULUNARY SURGERY. 
The important practical fact is, therefore, that cystitis (when neither 
tuberculous nor gonorrhoeal) is always a secondary, not a primary, mor- 
bid condition : we should begin our treatment of a case of cystitis by 
searching for the pre-existent cause and removing it when possible. 
The classical symptoms of cystitis are three : frequency of micturition, 
pain in urination, and pus in the urine. Yet the frequency and pain in 
urination are really caused by an irritation of the prostatic urethra rather 
than of the bladder. Hence when these symptoms are present they indi- 
cate prostato-cystitis rather than a cystitis proper; and in practice when 
we speak of cystitis we mean that the neck of the bladder (prostatic ure- 
thra), as well as the bladder-cavity, is inflamed—a prostato-cystitis. It 
is also important to remember that these symptoms may also be caused 
by an inflammation in the vicinity of the bladder, but outside of its 
cavity—of the seminal vesicle or of the lower end of the ureter. Infec- 
tion doubtless usually spreads from these to the bladder, so that a 
secondary cystitis does really exist. 
The treatment of prostato-cystitis endeavors first to discover the 
antecedent morbid condition, and second to recognize the variety of 
bacterial infection. As already stated, cystitis is secondary to some pre- 
existing lesion ; the commonest of these are gonorrhoea, a tight stricture 
of the dee]) urethra, prostatic enlargement, stone or tumor in the bladder, 
tuberculosis of the genital organs, and rectal abscess. Since these respec- 
tive conditions require widely different treatment, it is evident that there 
is no treatment applicable to cystitis in general: we must treat first the 
cause, by the removal of which we usually cure the cystitis—stretching 
a stricture, removing a vesical calculus, etc. 
It is true that we can often diminish the patient’s sufferings, even without 
removing the cause, by administering internal demulcents, such as santal oil, buchu, 
and alkalies, and by washing the deep urethra and bladder with hot water contain- 
ing a little borax or boric acid. But such treatment should be employed only to 
palliate the patient’s distress, while we dilate his stricture or treat any other lesion 
which may be causing the cystitis : to rely upon internal treatment or washing of 
the bladder for the cure of cystitis is irrational and futile. In a small percentage 
of cases of cystitis—which have become less numerous as our means for accurate 
diagnosis have improved—the most careful examination fails to reveal a local cause. 
In these cases we have to assume a constitutional cause for the local impairment 
of nutrition which makes cystitis possible—such as gout, lithiasis, etc.—and to 
treat the patient for these conditions. 
The surgeon should therefore never treat a cystitis without first examining 
carefully the entire urinary and genital tract and the rectum for local lesions; and 
he should remember the great frequency of tuberculosis of these organs as a cause 
of cystitis, especially in young men. 
Calculus is one of the common diseases of the bladder and a fre- 
quent cause of cystitis. A vesical stone consists chiefly of the normal 
urinary salts—phosphates, urates, oxalates—deposited upon a nucleus. 
In many cases this nucleus is a foreign body; in many others it is an 
aggregation of crystals imbedded in an albuminous substance. The 
greatest diversity of objects have been found enclosed in bladder-stones, 
such as a bullet, fragment of bone, piece of a catheter, of lead-pencil, 
straw, chewing-gum, hair-pin, blood-clot, fragment of necrotic tissue, 
clumps of pus, drops of oil. Some of these objects have been used 
Stone. STONE. 
489 
in irritating the urethra, and have slipped or been forced into the 
bladder. 
Before a calculus has attained much size it may be carried through the urethra 
with the flow of urine, or may become lodged in this channel, causing partial or 
complete retention of urine. After the constant deposit of urinary salts upon it 
has rendered its size too great for such passage the calculus can be removed only 
by surgical means: all attempts to dissolve it, either by internal medication or by 
local injections into the bladder, are futile. 
Conditions which favor calculus-formation are, possibly, the drink- 
ing of hard water and eating of albuminous foods in excess ; but certainly 
a frequent predisposing cause is chronic retention of urine, particularly 
when accompanied by alkaline fermentation of the retained urine: as 
these conditions frequently exist as the sequel of prostatic enlargement, 
calculi are found with great frequency in the subjects of this disease. 
This is a most important clinical fact, because either of these conditions pro- 
duces severe cystitis, and the detection of one may cause the surgeon to forget to 
examine for the other. Thus many subjects of prostatic enlargement are permitted 
to carry in their bladders undetected stones because all the symptoms are assumed 
to be due to the prostatic disease. Moreover, the difficulty of detecting a calculus 
is much increased by the prostatic enlargement and the pockets in the mucous 
membrane so common in such cases. 
Symptoms.—The symptoms caused by a vesical calculus vary greatly 
in severity according to the size, mobility, roughness, and location of 
the stone. A small stone encysted in a pocket away from the bladder- 
neck may cause but little distress, while a calculus which is rasped 
against the sensitive bladder-neck occasions severe pain. 
The symptoms are in general those of cystitis—unduly frequent and 
painful urination, with pus, sometimes blood, in the urine : pain felt in 
the perineum, rectum, and along the urethra, especially the glans penis, is 
usual. The pain and frequency in urination are commonly increased by 
active bodily movement, riding in wagons, etc., and diminish during rest 
in bed. Sometimes reflex pains in other parts of the body—the sole of 
the foot, instep, chest, or arm—have been known to disappear upon the 
removal of a vesical calculus. Particles of gravel may be brought away 
with the urine. 
Diagnosis.—Stone in the bladder must be distinguished from other 
causes of cystitis, of which prostatic enlargement, tight stricture, tuber- 
culosis of the bladder-neck, and vesical tumor are the most common. A 
calculus may coexist with any of these, and is very common with long- 
standing cystitis from prostatic hypertrophy; tuberculous ulcers and 
tumors of the bladder are often plastered over with phosphates, which 
may attain the size and dignity of a calculus. 
In every case in which the symptoms suggest a vesical calculus, even 
though one of the other conditions (excluding tuberculosis) is present, 
an examination of the bladder should be made. The means employed 
are—(1) the stone-searcher or short-beaked sound; (2) the cystoscope; 
and (3) digital exploration through a suprapubic incision. 
In the majority of cases a stone in the bladder can be detected by the short- 
beaked sound of small calibre (15 to 20 French). Before using this instrument 
the bladder should be irrigated with clean water, about five ounces of which are 
finally allowed to remain in its cavity. The patient lies horizontally with his hips 
somewhat elevated; the well-lubricated instrument is gently introduced, and the 
beak made to touch every part of the vesical wall. In a certain number of cases 490 
GEN I TO- URINA R Y S UR GER Y. 
a calculus escapes detection for one of the following reasons: (1) the sound may 
not enter the bladder, its point remaining in the prostatic urethra; (2) the pain 
may be so great that the bladder contracts, forcing out the water necessary to dis- 
tend it; (3) the stone may be so enveloped by a soft covering—the mucous mem- 
brane (so-called pocketed or encysted stone), pus, or blood—that the sound fails to 
touch the calculus ; (4) in cases of enlarged prostate, when portions of this gland 
project into the bladder, a stone may be so situated, above or below these pro- 
jecting masses, that the beak of the instrument cannot by any manipulation be 
brought into contact with it. Some of these difficulties are decreased by anaes- 
thesia, which indeed permits a more thorough examination; even then, however, 
the third and fourth of the above conditions may prevent the detection of the 
stone. 
The cystoscope has repeatedly discovered vesical calculi which the sound had 
failed to reach, even with the aid of anaesthesia. When this instrument is not 
available it is generally wiser to advise a digital exploration than to assert the 
absence of a stone when symptoms of severe chronic cystitis cannot be explained 
by the existence of other causes. 
Treatment.—The detection of a vesical calculus is a demand for 
immediate operative treatment: efforts at dissolving the stone are a 
waste of valuable time. 
The surgeon has a choice of two operative measures: (1) crushing 
of the stone in the bladder and removal of the fragments by irrigation— 
lithotrity; and (2) removed of the calculus entire through an incision— 
lithotomy. The crushing operation is now usually done at one sitting, 
and is then termed litholapaxy; and the incision for the removal of the 
entire stone may divide the membranous urethra (median lithotomy), the 
prostate and perineum (lateral lithotomy), or the prevesical tissues 
(suprapubic lithotomy). The choice among these four operations must 
be determined by the conditions existing in each case; their relative 
advantages are as follows: 
Litholapaxy has only one point of superiority over the others, though 
this is sometimes important—namely, its freedom from cutting; this 
advantage is appreciated by the patient rather than by the surgeon. 
The danger of septic infection from the cutting operations is now much 
less than formerly, and is not entirely absent from litholapaxy. 
Median lithotomy affords a rapid and safe removal for small stones; 
it is not adapted to larger ones nor to cases where the prostate is 
enlarged. 
Lateral lithotomy was until 1880 the usual cutting operation, since it 
permitted the extraction of large stones without regard to the size of 
the prostate. In the last fifteen years, however, it lias fallen into dis- 
use, having been replaced by 
Suprapubic lithotomy, which affords perfect access to the bladder and 
extraction of large stones w-ithout any damage to the sensitive bladder- 
neck. 
The disadvantages of litholapaxy are three: (1) the length of time, 
and hence of anaesthesia, required; (2) the impossibility of grasping 
and crushing a stone which is encysted or ensconced behind a prostatic 
enlargement or one which is very hard ; and (3) the chance that a minute 
fragment may remain in the bladder and thus form a nucleus for a new 
stone. 
The disadvantages of the cutting operations, on the other hand, are the 
patient’s natural repugnance to the knife and the greater chance of 
septic infection. While the latter still exists in cases where the urine STONE. 
491 
is foul, yet the mortality from it lias been much reduced by the combi- 
nation of suprapubic cystotomy with perineal drainage. 
Surgeons (litter in their choice of stone operations according to their 
estimate of these relative features, as well as according to their experi- 
ence with the various methods. They are generally agreed upon the 
following : 
(1) The suprapubic operation should be made when either the stone 
or the prostate is very large, the kidneys impaired, or the subject under 
twelve years of age; (2) in cases of small calculi, normal prostate, and 
healthy kidneys the surgeon chooses litholapaxy, median or suprapubic 
lithotomy, according to his own judgment of the case. Hence the supra- 
pubic operation is decidedly the most frequently performed. In boys 
before puberty the urethra is small and the bladder high in the pelvis, 
making the suprapubic operation preferable, although some surgeons still 
advocate litholapaxy or lateral lithotomy for these cases. 
The cutting operations which are made for purposes other than the 
extraction of stone are described in the section on “Operations,” p. 511. 
Litholapaxy is thus performed: If the stone be small, it may be 
removed without great pain and without general anaesthesia: four 
ounces of cocaine solution, one grain to the ounce, injected into the 
bladder, may suffice for the mitigation of suffering. Otherwise the 
patient is thoroughly anaesthetized. The rectum having been emptied, 
the bladder, which should have been cleansed for several days pre- 
viously, is again thoroughly irrigated with borax-water, four to six 
ounces of which are finally permitted to remain ; a rubber tube may be 
tied lightly around the penis just behind the glans to prevent the escape 
of water. The urethra is filled with oil or liquid vaseline and the 
lithotrite introduced. Its shaft is held at an angle of forty-five degrees 
with the table, its beak then making a depression in the floor of the 
bladder, into which the stone may roll; the male blade is then with- 
drawn an inch or more with the hope of catching the stone in the jaws 
of the instrument. If the stone be felt, the instrument is locked and the 
male blade screwed home; then the opening and closing of the blades 
are repeated until no large fragment can be detected. 
The actual process is, however, rarely so simple: there may be considerable 
difficulty in catching the stone in the beak, which must often be turned from side 
to side and carried into different parts of the bladder before the calculus can be 
distinctly caught between the blades; and the same fishing process may have to 
be repeated with the larger fragments resulting from the first crushing. Some- 
times the catching of the stone is facilitated by changing the position of the 
patient, especially by the elevation of the hips. It is very important, especially 
for one inexperienced in the operation, to remember never to close the blades except 
when the beak is in the upright position; otherwise the bladder-wall may be lace- 
rated. The crushing should be done as completely as possible before the instru- 
ment is withdrawn. 
The lithotrite is then removed and the large tube of the evacuator 
inserted. When its point has entered the bladder the communication 
between tube and bulb filled with water is opened, the water in the 
bladder driving the air out of the tube into the bulb. The pumping 
process is then begun and continued until no further clicking of frag- 
ments against the tube can be detected. After withdrawal of the 
evacuator the urethra is thoroughly irrigated. 492 
GENITO-URINARY SURGERY. 
Some cystitis follows so much instrumentation; it must be treated 
by irrigation, suppositories, etc., and after its subsidence the bladder 
should be again washed through the evacuator. 
Various complications occur during and after litholapaxy, such as 
hemorrhage, clogging of the blades of the lithotrite with debris, clogging 
of the evacuating tube, and breaking of the lithotrite (which should 
always be tested on a brick before the operation); any of which may 
test the surgeon’s judgment and ingenuity. 
Tumors of the Bladder.—The use of the cystoscope and the prac- 
tice of digital exploration of the bladder, both of which measures have 
been employed only since 1881, have shown that bladder-tumors, 
formerly considered rare, are by no means infrequent. They are found 
oftener in males than in females, and usually after the age of thirty 
years. Although many varieties of histological structure have been 
Fig. 214. 
Villous tumor (papilloma) of bladder (Mus6e Dupuytren). 
observed, we may for practical purposes specify three classes : papilloma, 
fibroma (both benignant), and cancer (malignant). 
Symptoms.—Bladder-tumors usually give rise to three symptoms— 
hemorrhage, pain, and cystitis. Hemorrhage occurs from nearly all blad- 
der-tumors at some stage of their growth. It is often distinguished from 
the hemorrhage due to calculus by three features : (1) its occurrence inde- 
pendently of exercise, as it often happens during sleep ; (2) its abundance, 
the bladder perhaps filling with clots; and (3) its increasing frequency. 
Pain due to the growth itself is caused more frequently and earlier 
by malignant than by benignant growths, and by tumors near the blad- 
der-neck than by those more remotely situated ; it is felt in the urethra, 
glans penis, rectum, and thighs. Such pain is of course to be distin- 
guished from that due to the bladder inflammation. 
Cystitis is a common, though often a late, result of a bladder-tumor. STONE. 
493 
The diagnosis seeks to establish first the existence of a vesical growth, 
and then its degree of malignancy. 
The symptoms caused by either variety are not always sufficient in 
the early stages to distinguish it from certain other morbid conditions, 
particularly tuberculosis and stone ; although the sound and the exami- 
nation of the sediment for tubercle bacilli afford a probable means for 
excluding these. Digital examination per 
rectum and bimanual palpation when the 
bladder is nearly empty sometimes disclose 
an unnatural hardness, thickening, and lack 
of symmetry of the prostate and recto-vesical 
tissues. 
There are but two positive proofs of the 
existence of vesical tumor—the discovery in 
the urine of fragments of the growth, and 
ocular detection by the cystoscope. 
The determination of the malignancy of 
the growth is sometimes easy, at other times 
difficult or impossible. A bladder-tumor in 
a young person, causing much hemorrhage 
and no pain, is generally a benignant papil- 
loma ; a tumor in an old person, causing constant, severe, and radiating 
pains, is usually malignant. Between these two extremes are many cases 
in which the degree of malignancy can be only conjectured, even when 
fragments are found in the urine or caught (as they may sometimes be) 
in the eye of a catheter. 
Cystoscopic Examination.—In every case of suspected bladder-tumor 
Fig. 215. 
Tumor of bladder as seen with 
cystoscope (Nitze). 
Fig. 216. 
Illumination of anterior vesical wall by Nitze’s cystoscope. 
—indeed in every case of obscure bladder disease—the interior of the 
organ should be inspected through the cystoscope. 
Tumors will usually be found at or near the trigone, at least 80 per cent, occu- 
pying this portion of the bladder. Papillomata can be easily recognized as slen- 
der, warty growths, similar to the pointed condylomata of the external genitals; 494 
GENITO-UBINARY SURGERY. 
fibromata are less easily distinguished from the folds of mucous membrane. Can- 
cerous growths are usually sessile tumors, whose surfaces, however, may be ragged, 
ulcerated, or papillomatous; this latter feature has led to much confusion of the 
malignant with the benignant papillomata. The distinction exists in the base 
rather than in the surface of the growth ; the color of the surface is, however, im- 
portant, the benignant tumors being pink and the malignant gray. 
A transformation from benignancy to malignancy certainly occurs sometimes 
in these bladder-tumors; operative removal, if incomplete, seems to hasten this 
transformation. 
Treatment.—This is palliative and radical. The arrest of hemor- 
rhage is often accomplished by the internal administration of turpentine 
oil, three to ten drops on sugar or in emulsion three to five times daily; 
clots can be removed from the bladder by washing, through a catheter, 
with warm water, to which a little pepsin or papain may be profitably 
added. Pain is of course to be controlled by morphine subcutaneously 
or by rectal suppository. In cases of inoperable malignant growth pain 
and cystitis may become so severe as to require the institution of a per- 
manent suprapubic fistula for the exit of urine. 
Radical operation means the excision of the tumor, which should 
always be undertaken through a suprapubic incision. The results of 
such excision have been very favorable for benignant, but unsatisfactory 
for malignant, growths, for in the latter class the anatomical relations 
render the complete removal of the base of the growth difficult, often 
impossible. Extirpation of a vesical cancer often requires resection of 
the bladder-wall, and has even then been followed by early recurrence. 
In general it may be stated that vesical growths which have infiltrated the 
bladder-wall, as revealed by the finger in the rectum or after incision in the blad- 
der, are not suitable for radical operation; those, on the other hand, whose bases 
are normal tissue, can be removed with a fair prospect of perfect recovery, or at 
least a long period of freedom from recurrence. 
Tuberculosis.—Primary tuberculosis of the bladder is very rare; 
in nearly all cases the infection has spread to this organ from the pros- 
tate or the kidneys. Its consideration is therefore included in the 
account of prostatic and renal tuberculosis. The discovery by the eys- 
toscope of shallow ulcers, and by the microscope of tubercle bacilli in 
the urinary pus, is the requirement of diagnosis. In one case seen 
by the writer the most prominent clinical feature was the frequent pas- 
sage of phosphatic sand ; the cystoscope revealed two ulcers coated with 
phosphates. 
Pericystitis ; Pelvic Inflammation and Abscess. 
The connective tissue of the male pelvis is not infrequently the seat 
of inflammation and suppuration, the results of extension of a septic 
infection from the various pelvic organs. This connective tissue con- 
sists anatomically and clinically of three portions: (1) that which en- 
closes the rectum ; (2) the broad ligament (enclosing the seminal vesicles, 
ampullae, and utricle); and (3) the perivesical tissue. The infections 
and inflammations are found clinically to correspond to this anatomical 
division. 
Infection of the connective tissue constituting the broad ligament is an 
extension from septic processes in the seminal tubes and prostate; its 
symptoms are therefore those exhibited by inflammation of the prostate DISEASES OF THE KIDNEY, PELVIS, AND URETER. 
495 
and appendages. When suppuration occurs the pus may break through 
the broad ligament in any direction—the peritoneum, rectum, perineum, 
or bladder: such disastrous burrowing of pus should be prevented by 
prompt incision of the abscess either from the perineum or (rarely) from 
the rectum. 
Infection of the pelvic connective tissue in front of the broad liga- 
ment, including the suprapubic space or cavity of Retzius, commonly 
results from extension of an inflammation from the bladder; it is espe- 
cially common in the prevesical space. Less frequently suppuration in 
this space results from the burrowing of pus from a distant abscess, such 
as an appendicitis. The usual symptoms of suppuration and cystitis, 
with a hard swelling above the symphysis, mark this condition and 
should suggest an incision into the prevesical space. 
Diseases of the Kidney, Pelvis, and Ureter. 
Infections.—The upper urinary passages are subject to three bacterial 
invasions : gonorrhoeal, septic, and tuberculous. 
Gonorrhoea occasionally extends from the bladder into and through 
the ureter to the kidney-pelvis and renal tubules, making a gonorrhoeal 
pyelo-nephritis. Such invasion is marked by the occurrence of chills, 
fever, pain, and tenderness extending from the kidney along the course 
of the ureter to the corresponding testicles, and by pyuria. With the 
cystoscope pus may be seen issuing from the ureteral orifice. 
Treatment.—In the female, where the ureter can be catheterized, 
irrigation of this canal and the kidney pelvis with hot water containing 
hydrastin muriate (saturated solution) or potassium permanganate 
(1 : 3000) can be made; in the male such local treatment is as yet 
impracticable. 
In both sexes guaiacol (twenty minims mixed with an equal volume of olive oil 
or glycerin) should be rubbed into the skin of the loin and abdomen over the kid- 
ney and ureter twice daily, and santal oil, boric acid, or salol given internally. In 
a few recorded cases the gonorrhoeal infection has caused abscesses in the renal 
tissues ; and in one such case (Weir) nephrectomy was successfully performed. 
Septic Infection: Pyelitis, Pyelo-nephritis, Surgical Kidney.— 
These various forms of septic infection are frequent sequels of chronic 
septic infection of the bladder (chronic cystitis), especially in cases where 
there exists a chronic obstruction to the exit of urine, such as prostatic 
enlargement, vesical calculus, and tight stricture of the deep urethra: 
in such cases first the ureter and then the pelves become distended with 
urine. Septic infection of the upper urinary tract may be provoked by 
catheterism in the puerperal state, doubtless through infection of the 
bladder. In all cases of long-standing cystitis, especially in elderly men, 
the possibility of this condition must be investigated, since treatment and 
prognosis are determined largely by its presence or absence. 
When acute, septic invasion of the upper urinary passages is marked 
by chills, fever, pain over the kidney, along the course of the ureter, 
down the thigh, and in the corresponding testicle, which may be retracted ; 
it is, however, more frequently chronic, and is then a gradual and insidi- 
ous process, whose symptoms are usually masked by the more pronounced 
signs of the coexistent cystitis. 496 
GENITO- TJRINAR Y SURGER Y. 
In a few cases an acute septic infection of the kidney and its pelvis occurs from 
the blood-current, and not by extension from the bladder; it is then a complica- 
tion of general infections, such as typhoid fever, osteomyelitis, diphtheria, etc. 
Suppurative pyelitis also follows the formation of a renal calculus. 
Treatment.—Internal medication, by salol or other antiseptic, is 
usually fruitless; the local application of guaiacol, and in the female the 
irrigation of the renal pelvis, as described in the preceding section, 
should be tried. 
Fig. 217. 
Double uretero-pyelo-nephritis, with portion of greatly thickened bladder-wall. Ureters dilated 
and shortened. Kidneys showing changes characteristic of pyelo-nephritis (Mus6e Guyon). 
Rational treatment consists in arresting the cystitis of which the pyelitis is the 
extension: this may be accomplished by the careful dilatation of the urethral 
stricture, the removal of the vesical calculus, tumor, etc. In cases of severe cys- 
titis and pyelitis from prostatic enlargement, simple drainage of the bladder for a 
few weeks has been followed by a cessation of the inflammation in the upper urin- 
ary channels. In cases where the septic infection has invaded the kidney struc- 
ture with the production of multiple abscesses—the so-called “surgical kidney”— 
cure has not often been obtained, and then only by incision and drainage of the 
kidney (nephrotomy) or by the removal of the organ. DISEASES OF THE KIDNEY, PELVIS, AND URETER. 
497 
Pyonephrosis.—This term designates an accumulation of pus dis- 
tending the renal pelvis and sooner or later destroying the kidney sub- 
stance. It is caused by a combination of septic infection with an obstruc- 
tion to the escape of urine from the ureter, this duct being occluded by 
a calculus, stricture, fragment of tissue, tumor in the bladder, or uterine 
tumor compressing the lower end of the ureter, etc. 
Pelvis and kidney are converted into a pus-sac; the occlusion of the 
ureter may entirely prevent the escape of this pus into the bladder, so 
that the urine (from the opposite kidney) may be clear and normal. 
Sometimes the occlusion is intermittent, in which case pus escapes into 
the bladder and mingles with the urine for some days, and is then shut 
off for a similar period. The pus-sac may be so large as to be distinctly 
Fig. 218. 
Hydro-pyonephrosis (Richardson). 
perceptible as a tumor in the renal region. Spontaneous recovery, 
though rare, has been known to occur by the escape of the contents 
through the ureter into the bladder, or by ulceration and discharge into 
the intestine or the lung. 
Treatment.—The diagnosis having been established by aspiration of 
the tumor, a nephrotomy should be made. If a renal calculus be found, 
its removal will be the only measure necessary ; if no apparent cause for 
the pyonephrosis be detected or tuberculosis be discovered, the advisability 
of immediate nephrectomy may be considered. The best practice is, how- 
ever, simply to drain, not immediately to excise the kidney ; for drainage 
is often followed by complete recovery, and if a fistula persists, nephrec- 
tomy can be made later with less danger of a fatal result. In a few 
cases simple aspiration of a pyonephrosis has been followed by recovery. 498 
GENITO- UR IN A BY SUR GER Y. 
Tuberculosis of the kidney may occur at any time of life, though 
most frequent in youth. It may occasion no symptoms beyond an 
admixture of pus and a little blood with the urine, some tenderness 
over the kidney, frequent urination, and a slight but constant increase 
of body temperature. When clots of pus or tissue-fragments occlude 
the ureter, however, then renal colic and pain in the testicle are felt. 
The infection is apt to spread to the bladder, after which the symptoms 
of severe cystitis supervene. 
When tubercle bacilli are discovered in the urinary pus the diagnosis is posi- 
tive; it is probable when the renal symptoms just mentioned are associated with 
tuberculous infection of epididymis and prostate, of lungs, joints, and other tissues. 
Fig. 219. 
Tuberculosis of kidney: multiple abscesses and degenerations (Richardson). 
Otherwise renal tuberculosis can be only suspected, and can be distinguished from 
other causes of pyelitis only when the kidney is exposed to view through an 
incision. 
Treatment.—Many cases of complete recovery after removal of 
the infected kidney have been recorded; in many others such removal 
has been followed by death from uraemia, the autopsy disclosing exten- 
sive though unsuspected tuberculosis of the opposite kidney and of 
other organs. The impossibility of proving before operation that the 
tuberculosis is limited to the suspected kidney has caused a diversity 
of opinion among surgeons as to what course is best; probably a neph- 
rotomy, thorough curetting of the diseased tissues, followed by the 
hygienic and medicinal treatment for tuberculosis in general—guaiacol, 
a dry sunny climate, etc.—are safest and best. 
Calculus. 
Stones are found in the kidney at all ages and in both sexes, the 
majority of cases being in the second half of life and in males. They CALCULUS. 
499 
are usually composed of uric acid, urates, or oxalates; more rarely of 
phosphates, cystin, or xanthin. 
The causes of the calculus-formation are generally constitutional, 
such as the gouty condition, though a foreign body, such as a clump of 
pus, of mucus, blood-clot, or fragment of tissue, is commonly found as 
the nucleus on which the urinary salts have been precipitated. Calculi 
found in the living subject vary in size from minute aggregations of 
crystals to stones weighing over two ounces, and in numbers up to 
hundreds; the severity of the symptoms bears no relation to the size 
of the stone, since small sharp concretions may cause the most acute 
distress. 
Symptoms.—These vary extremely in degree from distracting suffer- 
ing to almost nothing. Three symptoms are commonly present—pain, 
pyuria, and hcematuria; and several others are frequent-—disorders of 
micturition, nausea, and vomiting. 
Pain is felt in the renal region, along the ureter, in the testicle, and 
down the thigh; sometimes also in the opposite kidney; it is commonly 
intermittent. At intervals the pain is apt to be aggravated into a series 
of agonizing paroxysms called renal colic, so severe that nothing but 
chloroform can mitigate the suffering. Renal colic is due to spasmodic 
contractions of the pelvis and ureter ; sometimes it is provoked by the 
passage of a small calculus into and down the ureter, and ceases abruptly 
when the stone enters the bladder; but it may occur when the ureter is 
clear, and seems then to be provoked by the irritation of a stone in the 
pelvis. 
Pyuria is an almost constant symptom of renal calculus, the pus 
being derived from the inflamed pelvis and ureter. 
Hcematuria is not observed in every case, and is generally inter- 
mittent, being provoked by exercise or jolting in a vehicle. 
Frequency of urination with some pain is not rare, and should be 
remembered as a feature of renal irritation, because when associated 
with pus in the urine the symptoms are often erroneously ascribed to a 
cystitis. 
Nausea and vomiting are occasional features in the course of renal 
calculus; they are almost constant during renal colic. 
Diagnosis.—In cases presenting all the symptoms just described the 
diagnosis is simple; but since in many cases some of these symptoms— 
indeed almost all except pyuria—may be absent, the differentiation 
between renal calculus and pyelitis due to other causes, especially tuber- 
culosis, is difficult. 
In every case of pyelitis the surgeon should make a microscopic examination 
of the urine, noting pus, blood, crystals, and bacteria; the epithelium present is 
of no particular value in differential diagnosis. Then with the cystoscope it can 
be seen from which ureter the pus issues, and from the conspectus of symptoms 
a diagnosis of greater or less certainty is made. It must be said that after most 
careful and thorough examination competent surgeons have opened the kidney in 
the full expectation of finding a calculus, but with negative result, though in sev- 
eral of these cases the drainage has resulted in a cure of the pyelitis. In some 
cases only minute concretions, as large as pin-heads, have been found, but their 
removal has effected a cure. Hence a strong probability of renal stone warrants 
an exploratory incision if the general condition be favorable. Possibly the new 
rays called by Rontgen’s name may ultimately be of service in making a positive 
diagnosis of renal calculus by the photographic or phosphorescent plate. 500 
GENITO- URINAR Y SURGER Y. 
Treatment.—In every case of suspected renal calculus medicinal 
treatment may be tried, not with the hope of dissolving a stone of con- 
siderable size, but for the purpose of mechanically washing down into 
the bladder small concretions; for, as already stated, the small, even 
minute concretions sometimes cause the severest symptoms, even when 
no appreciable calculus is present. 
Medicinal treatment consists of restriction of the albuminous and 
saccharine articles of diet to a minimum, avoidance of constipation, 
and the free ingestion of pure water containing alkalies; whether the 
solution be natural or artificial is probably immaterial. The popular 
belief that lithia compounds and spring waters containing them have 
an especially good effect is hardly warranted by clinical experience ; the 
same remark applies to the various remedies sold as solvents, such as 
piperazine. The nitrates and acetates of sodium and potassium—one 
to two drachms daily, dissolved in two quarts or more of water—may 
be substituted for the natural alkaline waters, such .as Carlsbad or 
Vichy. In case of persistent nausea, flushing of the kidney can be 
easily secured by injection of the water into the lower bowel. 
Such treatment has repeatedly caused the expulsion of small stones 
and a restoration of the normal condition of the kidney pelvis and 
ureter. Yet it usually fails, in which case surgical means must be con- 
sidered. This consists in an incision down to the kidney, a careful 
digital examination of the organ, its pelvis and the upper part of the 
ureter; and if a stone be detected (or even otherwise in the judgment 
of the surgeon) an incision through its substance. If no calculus be 
touched by the finger-tip passed into the kidney pelvis, a long probe 
(uterine or other), bent into the shape of a very short-beaked sound, 
may be used to explore the calyces of the kidney; and a flexible probe 
should be passed down the ureter to the bladder, since a stone lodged 
in the lower segment of the ureter may give all the symptoms of renal 
calculus. 
Some surgeons recommend, after exposing the kidney, the exploration of its 
tissue and pelvis by repeated punctures with a needle, a negative result causing 
them to refrain from incising the kidney itself. Such exploration should, however, 
never prevent the incision and digital exploration of the pelvis. 
In some cases the kidney tissue is found practically destroyed by the 
pressure-atrophy and suppuration consequent upon the stone-formation ; 
yet after drainage complete healing will commonly occur, so that the 
more dangerous operation of nephrectomy, as practised by some under 
these circumstances, is to be avoided. 
Enlargements of the kidney and its pelvis are of three kinds: (1) 
distention with retained urine or pus; (2) cysts; (3) neoplasms. The 
first class includes pyonephrosis (already described) and 
Hydronephrosis.—This term designates a chronic distention of the 
kidney pelvis, calyces, and renal tissue with urine, due to a partial or 
intermittent obstruction to the exit of urine. Complete and permanent 
occlusion causes, not hydronephrosis, but arrest of secretion and atrophy 
of the kidney. 
Tumors. TUMORS. 
501 
The obstacle to the passage of urine from the kidney may be located 
in the ureter—such as a stone, blood-clot, valvular arrangement of the 
mucous membrane, a “kinking” due to displacement of the kidney; or 
in the bladder, such as a tumor at the ureteral orifice, a calculus, or pros- 
tatic enlargement; or, finally, in the urethra, as a tight stricture or a 
minute meatus. As some of these conditions are congenital, hydrone- 
phrosis likewise may exist at birth. 
The effects of such obstruction are gradual dilatation of the pelvis and kidney 
tissue, and finally atrophy of the latter, the kidney and its pelvis being trans- 
formed into a membrane-like sac. This sac may contain many ounces, even gal- 
Fig. 220. 
Hydronephrosis from obliteration of ureter by tubercular disease (Tuffier). 
Ions, of fluid, which, while at first urine, gradually loses its urinary constituents 
and assumes a cystic character. If infection occur, a suppurating hydronephrosis, 
and finally pyonephrosis, results. 
Symptoms.—The gradual development of a hydronephrosis occasions 
no pronounced symptoms, although the obstructing cause, such as a cal- 
culus in the ureter, may produce acute signs. Sometimes a dull pain is 
observed and undue frequency of urination noted; commonly, however, 
the swelling is the first symptom. Sometimes this tumor undergoes 
rapid decrease in size corresponding to a greater escape of the retained 
urine, and such cases of intermittent hydronephrosis are apt to have 
mild renal colic. 
The diagnosis is made probable by the history and detection of a 
fluctuating tumor; it should be confirmed by careful aseptic aspiration, 
which alone can furnish positive differentiation from other kidney tumors 
and from ovarian cysts. 
Treatment.—Rational treatment would be the removal of the obstruc- 
tion. To this end medicines are useless : a few cases have been relieved 
by mechanical means, such as massage of the tumor, inversion of the 502 
GENITO- UIITNAR Y SURGER Y. 
patient, or aspiration through the loin. Usually, however, operative 
interference is necessary. 
Surgical treatment may be either nephrotomy or nephrectomy, made 
through a lumbar or transperitoneal incision, most surgeons preferring 
the former. 
Nephrotomy—or more accurately pyelotomy, since in this case the dis- 
tended pelvis rather than the kidney is incised—is the operation of choice, 
Fig. 221. 
Hydronephrosis in first stage of development (Rayer). 
the sac being stitched to the skin. Then a careful search is made for ob- 
structions in the ureter; a stone or clot is removed, a stricture divided, etc. 
Often the obstruction cannot be detected nor removed, yet sometimes the 
result is a cure even when nothing beyond simple incision and drainage 
is done. If, however, a permanent fistula, discharging large quantities 
of urine, persists, the advisability of nephrectomy must be considered. 
Cysts.—Two varieties of renal cysts come to the attention of the 
surgeon—conglomerate (cystic degeneration) and hydatid. 
Cystic degeneration of the kidney is often congenital, and sometimes 
in later life acquired; usually both kidneys are involved. It causes 
vague symptoms suggestive of chronic nephritis—light, pale, albuminous, 
perhaps bloody urine; cardiac hypertrophy; occasionally a perceptible 
renal tumor; oedema of the lower extremities. 
Medical and surgical treatment are alike useless. MOVABLE AND FLOATING KIDNEY. 
503 
Hydatid cysts of the kidney are rare, and cannot be distinguished 
from other fluid tumors unless the characteristic hooklets or daughter- 
cysts are discovered in the urine, or by aspiration, or after rupture into 
adjacent organs. 
The treatment is incision to the tumor, evacuation of the sac, 
excision of so much of it as is accessible, and stitching of the remainder 
to the skin. 
A few cases seem to have recovered after the injection of half a drachm of mer- 
curic bichloride solution (1: 1000) into the cyst, whereby the parasite is destroyed 
and absorption of the cystic contents promoted. 
Neoplasms (solid tumors) of the kidney are benignant or malignant; 
the former are not common. The malignant tumors—carcinoma, sar- 
coma—occur as secondary or primary growths; the latter are most 
frequent in infancy and in advanced life, often attaining great size in 
the younger patient—ten to twenty pounds. The cancer remains for a 
long time enclosed within the kidney capsule, though metastases may 
early occur. 
The symptoms of renal cancer are pain, hsematuria, dilatation of 
superficial veins, tumor, and cachexia ; the latter is the only constant 
feature. Pressure upon the common iliac vein or vena cava may cause 
oedema in one or both extremities, as well as enlargement of the veins 
in the abdominal wall, scrotum, and leg. 
The pain is more often dull than sharp or paroxysmal, though renal colic, due 
to plugging of the ureter by blood-clots or detached fragments of the cancer, may 
occur. The bleeding is intermittent, often severe, and appears without provoca- 
tion. 
The diagnosis is not always possible until the kidney is exposed ; the cachexia 
peculiar to cancerous patients and emaciation are important diagnostic signs. 
Treatment.—There is but one, nephrectomy. Cases in which the 
tumor and kidney have been extirpated before metastatic deposits 
existed have furnished a large percentage of cures; unfortunately, the 
difficulty of diagnosis has often prevented early operation. 
Abnormal mobility of the kidney may be congenital or acquired, and 
the range of movement may be behind the peritoneum, due to laxity of 
the renal attachment, or within the abdominal cavity, due to the 
enclosure of the kidney in a distinct envelope of peritoneum—a meso- 
nephron. The former is called a movable kidney, the latter—far less 
frequent—a floating kidney ; this anatomical distinction is not clinically 
practicable until the kidney is exposed. 
Practically, every abnormally motile kidney is a movable kidney; 
the condition is acquired, not congenital; in at least 90 per cent, of 
cases it is found in women, especially in those who have borne several 
children. 
Symptoms.—Pain varies from almost nothing to a severity that 
incapacitates the patient for active bodily movement. In the latter 
case a dragging pain in the abdomen, aggravated by movement, stand- 
ing, constipation, or menstruation, sharp pain, resembling renal colic, 
general abdominal distress with nausea, are frequently observed. 
Movable and Floating Kidney. 504 
GENITO- VRINAR Y SURGER Y. 
Palpation reveals a tumor which usually corresponds in size and 
shape with the normal kindey, though sometimes larger; this may be 
found even as low as the pelvic brim; indeed, it has been felt through 
the vagina: it can generally be pushed back into the normal locality 
either by the hand or by elevation of the patient’s hips. 
Treatment aims at the retention of the kidney in its normal posi- 
tion : to this end various trusses and bandages have been devised, and 
have sometimes in thin patients secured a proper fixation of the kidney. 
Usually, however, this organ must be exposed, and by means of three 
or four silk sutures, passed half an inch apart through the kidney sub- 
stance and the edges of the divided lumbar fascia, sewn firmly to the 
abdominal wall. This operation is termed nephropexy or nephrorrliapky: 
it is almost free from danger and affords a great probability of perma- 
nent relief. 
Renal Colic. 
Spasmodic contractions of the kidney pelvis and ureter are accom- 
panied with agonizing pain, called renal colic; painful retraction of the 
corresponding testicle is a common accompaniment. These contractions 
are provoked either by the irritation of a calculus in the pelvis or ureter 
or by any decided obstruction to the passage of urine into the bladder. 
They therefore occur in several conditions other than renal calculus, 
being caused by blood- or pus-clots, renal tuberculosis or malignant 
disease ; kinking of the ureter in cases of movable kidney; stricture 
or compression of the ureter by pelvic tumors or inflammatory exu- 
dates. 
The treatment should aim ultimately to remove the cause of the 
obstruction, but the severe pain requires present relief. The patient 
should be more or less completely inverted, a measure sometimes giving 
immediate and lasting relief from pain ; if it fail, hot fomentations, sub- 
cutaneous injections of morphine, or even prolonged inhalations of 
chloroform, are required. 
Perinephritis. 
Inflammation of the fatty and connective tissue surrounding the 
kidney is a somewhat frequent condition ; it is sometimes secondary to 
a general septic infection or to inflammation in adjacent organs—appen- 
dix, liver, colon ; and it is frequently primary. The usual causes of 
primary perinephritis are wounds and blows in the lumbar region, 
infections of the kidney substance and pelvis (pyelitis, tuberculosis), and 
perhaps the so-called gouty diathesis. 
The course of the perirenal inflammation varies with the cause; it 
results sometimes in a chronic thickening of the tissues, more commonly 
in suppuration. The abscess may long remain limited to the perirenal 
region, or it may soon burst into the colon, lung, peritoneum, or exter- 
nally, or it may burrow down into the pelvic connective tissues. 
Symptoms.—The usual acute form is marked by the regular symp- 
toms of septic inflammation—chills, fever, pain, and tenderness: 
there may be fixation and tenderness of the hip, closely simulating NEPHRALGIA.—RENAL HEMATURIA. 
505 
tuberculosis of this joint, but a distinct fulness of the lumbar region is 
apparent. 
The diagnosis is established by the aspirating needle. 
Treatment.—In many cases the morbid condition in the kidney 
itself overshadows the perinephritic inflammation both as to diagnosis 
and treatment. The perirenal process should be treated as are other 
septic infections; that is, before suppuration is evident by the external 
application of guaiacol, and after pus-formation by incision and drainage. 
Guaiacol, 15 to 30 minims, mixed with a equal volume of olive oil or 
glycerin, should be rubbed into the skin over the kidney two or three 
times daily; absolute rest and saline laxatives are required. If chills 
and high temperature or the aspirator reveal the presence of pus, incision 
and drainage should be promptly made; delay increases the possibility 
of rupture of the abscess into the peritoneum or of its burrowing into 
the pelvis. 
Nephralgia. 
Pain referred to the kidney is an obvious result of many of the mor- 
bid conditions already discussed, such as calculus, cancer, and ureteral 
obstruction. There are, however, cases in which severe and persistent 
pain in the kidney cannot be accounted for by an obvious lesion. In 
some of these a gouty condition associated with unduly acid urine has 
been assumed as the cause, and appropriate medical treatment has 
followed by diminution of the pain. In others, after the failure of 
internal remedies, an exploratory incision to or into the kidney has 
been made; in some of these eases a small calculus has been discov- 
ered and removed; in others, although nothing abnormal was detected, 
the pain has immediately and permanently ceased. In cases of severe 
and persistent renal pain, therefore, the failure of internal medication 
and of the local application of guaiacol justifies the consideration of an 
exploratory nephrotomy. Renal pain must be carefully distinguished 
from the frequent pain in the sacral region caused by chronic inflamma- 
tion of the prostate and appendages. 
Renal Hematuria. 
This is another symptom which, while regularly associated with ob- 
vious kidney disease, such as calculus and cancer, occurs in some cases 
without apparent cause. In some of these the bleeding seems to be due 
to malarial infection, because promptly relieved by quinine; in others 
the later history or an exploratory incision reveals malignant disease or 
a calculus; in at least one case excision of a kidney for prolonged and 
dangerous hemorrhage has shown a local brittleness of the renal vessel 
(local haemophilia). But many cases are on record in which an explora- 
tory incision, while disclosing no abnormality, has been followed by per- 
manent arrest of hemorrhage. 
Oil of turpentine in five- to ten-drop doses on sugar four times daily, and 
thorough massage of the abdomen and lumbar region, should fie tried before ope- 
rative measures are considered. The fact that these cases of apparently causeless 
bleeding from the kidney, arrested by simple incision, commonly occur in young 
women suggests the possibility of an emotional disturbance as a cause. 506 
GENITO-URINARY SURGERY. 
DISEASES OF THE TESTICLE AND EPIDIDYMIS. 
The acute diseases of these organs are due to gonorrhoea, septic infec- 
tion, and trauma, all of which have been described in Volume I.; acute 
inflammation of the testicle is also seen as a local manifestation of the 
general infection of mumps, typhoid fever, and other acute bacterial 
diseases. It requires the same treatment as gonorrhoeal orchitis. 
The chronic diseases are all accompanied by enlargement, general or 
local, of these parts, and the diagnosis of these diseases is therefore 
largely a comparative study of the swellings exhibited by these organs. 
Tuberculosis is primarily a disease of the epididymis, where the 
infection appears as irregular, hard, nodular swellings like shot, which 
may later coalesce into a cord, thus converting the epididymis into a 
rigid tube as large as the finger; subsequently the same changes may 
occur in the adjacent parts of the testicle and in the spermatic cord. 
The tubercular tissues in the epididymis may become adherent to the 
skin, soften, and ulcerate, making a small but obstinate sinus. 
Tuberculosis of the epididymis is soon followed, usually before the patient 
seeks medical advice, by the infection of the seminal vesicle and prostate; the 
remarks as to the age of patients, avenues of infection, and general treatment of 
“ tuberculosis of the prostate and appendages ” are therefore applicable here. 
Surgical treatment was formerly castration, with the idea of remov- 
ing the tuberculous focus and thus protecting the patient from further 
infection. Experience has, however, shown the fallacy of this idea, 
since the infection is usually established within the pelvis before the 
patient is brought to the surgeon. Conservative local treatment is the 
wise plan : before softening of the tuberculous foci has occurred guaiacol 
(twenty drops with an equal quantity of olive oil) should be rubbed into 
the diseased parts two or three times daily until the skin becomes sore, 
and then applied to the spermatic cord and groin. After softening has 
occurred the tissues should be thoroughly curetted and packed with iodo- 
form gauze: if the infection and softening have already involved most 
of the testicle, castration should be performed, not with the idea of pre- 
venting further infection, but simply (like the curetting) to remove 
broken-down tissue. Trichloride of iodine (1 part to 100 or 300 of pure 
water) has, in the writer’s hands, proved a most valuable agent for appli- 
cation to tuberculous cavities and tissues in the epididymis and testicle. 
Syphilis in the secondary and tertiary stages attacks first the testicle, 
and later the epididymis and cord, thereby offering a sharp contrast to 
tuberculosis of these parts. It makes a diffuse, smooth, painless enlarge- 
ment of the testis, which may double or triple the original size of the 
organ. 
The diagnosis must rest partly upon the history, but chiefly upon 
the effects of specific treatment—full doses of the iodides internally and 
blue ointment or other mercurial salve locally. Syphilitic enlargement 
of the testicle is extremely common, and it usually occurs years after the 
primary infection, when the patient has perhaps almost forgotten the 
incident: it is therefore an excellent rule never to remove a smooth, 
painless tumor of the body of the testis until a month of active treat- 
ment with iodides and mercurials has failed to make any impression 
upon it. DISEASES OF THE TESTICLE AND EPIDIDYMIS. 
507 
Within six months after the infection is acquired syphilis occasion- 
ally attacks the epididymis. This swelling is easily distinguished from 
the tuberculous infection, not only by the recent history, but also by 
the smoothness and painlessness of the enlargement. It yields readily 
to syphilitic treatment. 
Cystic Disease.—In middle life the testicle presents a cystic degen- 
eration distinct from the cystic formation that often accompanies sar- 
coma. It is a slowly-growing, painless tumor, whose fluid nature may 
be suspected from its indistinct fluctuation (which is, however, also 
shown by sarcomata); the aspirating needle can alone establish the 
diagnosis. 
Medical treatment is useless; castration is usually performed. 
However, since the cystic degeneration may involve only a part of the 
testis, it may be well for the surgeon after exposing this organ to incise 
it, and, if a considerable portion seems normal, to remove only the 
diseased part. 
Chronic Epididymitis and Orchitis.—Sometimes as a continuation 
of an acute infection, oftener as a purely chronic inflammation, the 
epididymis and the testis, one or both, exhibit a chronic enlargement 
designated by the above names. This condition seems often to be a 
continuation of the chronic inflammation so common in the prostate 
and seminal tubes, and already described in the “ Diseases of the Pros- 
tate and Appendages.” Sometimes the epididymis is alone affected, 
sometimes the testis alone, or both may exhibit the enlargement. This 
chronic inflammation causes a great and often uniform swelling of the 
organs; they are painful and sensitive to pressure. Acute aggravations 
of the inflammation, resulting in local abscess and sinus, are not rare, 
and ultimately cysts may develop. 
The diagnosis is sometimes very difficult; indeed, this condition 
is probably often considered tuberculous, cystic, or malignant disease, 
and castration is performed on this mistaken diagnosis. It must be 
distinguished from other enlargements by a careful comparison of the 
symptoms, by examination of the prostate and vesicles, and by the 
effects of syphilitic treatment. 
Treatment.—When chronic inflammation of the prostate and 
appendages is discovered, these should be treated by milking and irri- 
gation, as already described; in any case the effects of mercurial oint- 
ments to the testicle should be tried. Otherwise, the treatment is 
symptomatic—suspension of the organ, curetting of sinuses and abscess- 
cavities, etc. Ultimately castration is necessary in a considerable 
number of cases. 
Fibroma and enchondroma of the testicle are rare and clinically 
unimportant. 
Cancer of the testicle is a term used to designate two varieties of 
malignant growth, carcinoma and sarcoma, the distinction between 
which is often impossible without histological examination. 
Cancer of the testis is most frequent in the second half of life, 
though not rare before the completion of puberty. Its origin can often 
be distinctly traced to a blow, or a previously inactive tumor shows a 
rapid and malignant growth after such injury. 
In the early and slow stages there are no sharp diagnostic distinc- 508 
GENITO-URINARY SURGERY. 
tions from the non-malignant enlargements of the testicle already men- 
tioned : the active stage is, however, marked by rapid enlargement, con- 
stant pain, dilatation of scrotal veins, induration of the inguinal and 
pelvic lymph-nodes, and the cachexia and emaciation generally character- 
istic of malignant growths. The aspirating needle brings only blood. 
Treatment consists of castration and removal of infected nodes. 
Yet the records show a discouragingly large percentage of metastases 
in internal organs even after fairly early castration; the transfer of 
cancerous material to the pelvic nodes seems to occur at a startlingly 
early period. 
Diseases of the Spermatic Cord 
While the vas deferens and its envelope participate in many of the 
diseases of the testicle and epididymis and of the prostate and seminal 
vesicle, it exhibits three independent morbid conditions—hydrocele, 
spermatocele, and varicocele. 
Hydrocele of the cord is a collection of serous fluid in a portion 
of the peritoneal process surrounding the cord which has not undergone 
the usual obliteration after the descent of the testicle. It causes a 
painless swelling in the position of the spermatic cord and terminating 
above the testicle; its upper end may lie within the inguinal canal. 
It causes no symptoms, unless acute inflammation supervenes, when 
tenderness and pain are developed. 
The diagnosis is best made by an aseptic aspiration, which may 
also be the means for immediate injection of three or four drops of 
95 per cent, carbolic acid by way of treatment. Without aspiration it 
may be possible to recognize a hydrocele by its shape and distinct fluc- 
tuation, but it is sometimes difficult to distinguish it from omental or 
even intestinal hernia, with which it may indeed be complicated. When 
injection of carbolic acid fails, the sac may be incised, stitched to the 
skin, and packed with iodoform gauze. 
Spermatocele begins between testicle and epididymis, but extends 
upward along the spermatic cord, making an oval fluctuating tumor 
which appears to be inserted at the top of the testis or epididymis. 
The diagnosis is confirmed by microscopic examination of the fluid 
removed by aspiration (showing spermatozoa); if, after tapping, it again 
form, the sac may be opened and stitched to the skin. 
Varicocele—dilatation of the veins of the pampiniform plexus and of 
the spermatic cord—is a very common affection, found in perhaps 10 per 
cent, of adult males. Its clinical importance depends quite as much 
upon the popular belief that it causes sexual derangement as upon its 
real pathological effects. 
Varicocele commonly develops soon after puberty, when the sexual 
instinct is constantly active and imperfectly gratified ; a slight degree 
of venous dilatation often disappears after marriage. Varicocele is but 
rarely observed in the right half of the scrotum ; its almost constant 
restriction to the left side is usually explained by the tendency to venous 
congestion caused by two factors : first, the opening of the left spermatic 
vein into the renal vein at a right angle, and, second, the frequent com- 
pression of this left spermatic vein by a distended sigmoid flexure. DISEASES OF THE SPERMATIC CORD. 
509 
Symptoms.—The development of the varicose condition is nearly 
always gradual ; in rare cases—following violent bodily eflort or fatigue 
—it is acute. This acute form usually subsides under a few days’ rest, 
hot fomentations, and elevation of the testicles. 
The usual slowly-developing varicoceles are often discovered by accident before 
they have caused any subjective symptoms, but sooner or later the patient becomes 
aware of a sense of weight, possibly dull pain, in the testicle and sacral region, 
aggravated by bodily effort and by sexual excitement. In extreme cases the veins 
of the scrotum also exhibit the varicose condition. Mental symptoms—anxiety 
and despondency concerning the integrity of the sexual organs—are frequently 
pronounced, and the testicle may, in fact, become soft, sensitive, and ultimately 
atrophied. 
The diagnosis of uncomplicated varicocele is simple: the wormy 
feel of the tortuous vein is quite peculiar and unmistakable. If the 
patient be made to lie down, the dilated veins are emptied and the en- 
largement disappears; if he again stand, the surgeon’s fingers being 
meanwhile kept pressed against the external inguinal ring, the veins 
refill from below (unless the pressure is so great as to obstruct the artery 
also). The coexistence of hydrocele or hernia can be detected by this 
test. 
Treatment.—There are three symptoms requiring treatment: (1) a 
hypochondriac state ; (2) such pain and distress in the testicle, groin, and 
back as to seriously annoy and incommode; (3) wasting of the testicle. 
If none of these exist, the patient may be dismissed with advice as to 
sexual hygiene and with a suspensory bandage. If the mental symp- 
toms are prominent, general tonic treatment and cold douches locally 
should also be prescribed. If, in spite of support and mental treatment, 
either of the three symptoms persist, an operation should be advised. 
This is especially needful if the testicle be flabby, sensitive, or wasted; 
for after ligation of the varicose veins the condition of this organ im- 
proves—often, indeed, to the normal standard. 
Three operations for varicocele are more or less practised : (1) the 
amputation of the scrotum, which converts this sac into a natural sus- 
pensory bandage ; (2) subcutaneous ligation of the dilated veins ; (3) open 
ligation and excision of these veins. 
Amputation of the scrotum may be dismissed as an uncertain and unnecessarily 
severe operation: the choice really lies between subcutaneous and open ligation 
of veins. The former is practised and warmly advocated by several skilful sur- 
geons, notably Keyes, while the open method has the general preference, because 
by it the surgeon can see what and where to ligate. 
In ligation of the veins, whether subcutaneous or open, three vital points must 
be observed : (1) the vas deferens must be excluded from the ligature ; (2) at least 
three or four venous trunks must remain untied; and (3) the veins must be tied at 
the bottom as well as at the top of the scrotum—that is, at the globus minor of the 
epididymis as well as in the spermatic cord. The exclusion of the vas deferens 
secures the patulence not only of this important duct, but also of the spermatic 
artery which accompanies it: ligation of this artery has been known to cause 
necrosis or atrophy of the testicle. The obliteration of all venous trunks also 
renders atrophy of the testis probable; hence the necessity for leaving some 
untied. 
The third injunction—to tie at the bottom as well as at the top of the scrotum 
—is the result of the frequent experience that ligation of the veins above the tes- 
ticle only (in the spermatic cord) has often failed to cure the varicocele; for the 
veins of course fill from below, and such ligation leaves a large mass of dilated veins 
around the testicle constantly full of blood. 510 
GENITO-URINARY SURGERY. 
The operation is thus performed: The patient’s groin and scrotum 
are thoroughly shaved and cleansed ; a clean rubber band, applied while 
the patient stands, is made to constrict the scrotum, passing over the 
root of the penis : this organ is enclosed in aseptic gauze and kept out 
of the way against the suprapubic space by a bandage around the hips. 
Anaesthesia may be general or local (two drachms of a 1 per cent, 
cocaine solution injected into the skin over the cord and epididymis). 
A longitudinal incision two inches long divides the scrotum below the 
rubber band; the enlarged veins are lifted into the wound; the vas 
deferens—distinctly recognizable as a hard cord—is kept carefully away 
from the wound by the thumb and finger of an assistant; the bunch of 
veins, excluding three or four, is very tightly ligated en masse with silk 
at two points, above the testicle and opposite the globus minor; some 
surgeons place a third ligature between these two. The ligatures are 
cut short; a drain consisting of a few strands of catgut is carried 
through a puncture in the bottom of the scrotum; the wound dusted 
with iodoform and closed ; iodoform gauze dressing and rest in bed for 
a week follow. After this, as after other operations on the genitals or 
rectum, temporary retention of urine may occur, requiring the catheter 
for a day or two. 
Hydrocele. 
By hydrocele is meant an accumulation of serous fluid in the tunica 
vaginalis; it may be acute or chronic. The acute form is always second- 
ary to trauma, inflammation of epididymis or testicle, or a general infec- 
tion such as pyaemia. 
It usually subsides without other treatment than rest and hot 
fomentations; if suppuration occur, incision and drainage are needed. 
Chronic hydrocele is the condition meant by the term hydrocele unless 
otherwise specified. 
The fluid accumulates slowly and lasts indefinitely; the tunica and the sub- 
serous connective tissue may become greatly thickened and hardened ; calcareous 
deposits are observed and osseous formations are sometimes seen. The extreme 
thickening may involve the scrotum ; the opposing surfaces of the tunica become 
adherent, the fluid absorbed, and the entire mass—the testicle and its greatly thick- 
ened covering—constitute a solid tumor suggestive of cancer. This condition is 
considered a chronic inflammation, and is called periorchitis, adhesive or prolife- 
rating. 
Symptoms and Diagnosis.—Chronic hydrocele causes only mechan- 
ical symptoms—a swelling of the scrotum and a dragging sensation due 
to the extra weight. 
The diagnosis is not usually difficult: the tumor is pear-shaped and 
sharply limited outside of the inguinal canal (unless there be also hydro- 
cele of the cord); there is more or less distinct fluctuation. 
The classical test of translucence—interposing the tumor between a lighted 
candle and the surgeon’s eye—usually shows the translucence of the greater part 
of the mass, the contained testicle and epididymis being opaque. This test is less 
successful when there is much thickening of the connective tissues. The modern 
test is a clean aspiration, which must always succeed except in cases of advanced 
periorchitis with absorption of the fluid. 
Treatment.—There are two recognized modes of treatment: (1) 
the induction of an adhesive inflammation which shall unite the opposite OPERATIONS. 
511 
layers of the tunic and thus obliterate the cavity : this may be attempted 
by injection of irritating substances (carbolic acid) or by incision and 
packing (Volkmann’s operation); and (2) excision of the entire tunica 
excepting only the part adherent to testis and epididymis. 
Injection.—The scrotum having been carefully cleansed and the testicle grasped 
by the surgeon’s left hand, a large aspirating needle is passed into the sac away 
from the testicle, the fluid permitted to escape, and ten to twenty minims of 95 per 
cent, carbolic acid injected; the sac should then be so manipulated as to spread 
the injected acid over its surface—an important item. The patient is kept quiet 
for a day or two, and then permitted to go about with the testicle properly sup- 
ported. The scrotum again swells and becomes doughy, as if refilling with fluid, 
but in a week or so the new swelling subsides permanently. 
Cautions.—Tincture of iodine, formerly so much used for this injection, should 
never be employed, because the inflammatory reaction is sometimes extremely severe 
and followed by sloughing of the scrotum, with perhaps a fatal result. 
Great care should be taken, before the acid is injected, to see that the point of 
the needle is still within the cavity of the tunica; for the collapse of the sac as the 
fluid escapes may leave the needle outside of the serous cavity, in which case the 
acid would be injected into the scrotal tissues, causing serious damage. 
The only objection to this operation is its uncertainty, relapses of the hydro- 
cele being frequent. 
Free incision and packing of the sac with iodoform gauze, the cut 
edges of the tunica being sewn with catgut to the edges of the skin, is 
a simple and safe operation (done aseptically) which can be performed 
under cocaine anaesthesia. Unfortunately, it is not a certain cure, recur- 
rence having been occasionally observed. 
Excision of the sac, which can usually be peeled away from the adhe- 
rent scrotum before the sac is opened, is the only positive cure : the objec- 
tions are, first, that it requires general anaesthesia, and, second, that very 
free oozing of blood may occur from the raw surfaces unless firm pres- 
sure is maintained for a day or two after operation. 
The following operations, needful for the relief of various morbid 
conditions, have not been described in the text. 
Circumcision.—The patient, if a child, should be chloroformed; in 
an adult local anaesthesia is induced, after constriction of the penis by a 
rubber band around its root, by the subcutaneous injection into the dor- 
sum of the organ just in front of this band of a half drachm of a 10 per 
cent, cocaine solution. The parts are cleansed; a snap forceps seizes the 
muco-cutaneous junction of the foreskin on either side : by means of 
these an assistant draws the prepuce well forward from the glans, which 
is pressed back by the left hand of the operator. With sharp scissors 
(with or without the aid of a clamp) the foreskin is amputated just in 
front of the glans. The skin now retracts, while the cuff of mucous 
membrane remains over the glans; this cuff is split with scissors in the 
middle line (sometimes adhesions to the glans must be broken up by means 
of a probe), and each segment cut off close to the penis, leaving a fringe 
only about a quarter of an inch broad. The skin, if excessive, must be 
again drawn beyond the glans and another section snipped off. The 
constricting band is removed, any spurting vessels are twisted or ligated, 
and the cut edges of skin and mucous membrane arc united by eight to 
Operations. 512 
OENITO-URINAllY SURGERY. 
twelve interrupted catgut sutures, the stitches passing through the inter- 
vening subcutaneous tissues. The seam is dusted with iodoform or lore- 
tin, dressed with gauze, and a rubber condom (whose narrow neck is 
split to avoid constriction) is drawn over the hole. The tip of this con- 
dom is then cut off* and the edges fastened to the surface of the gland 
with collodion, to prevent leakage of urine into the dressing. 
Cautions.—The essential of success is the complete removal of redundant fore- 
skin, especially of the mucous layer, of which only enough should be left for the 
insertion of stitches—not more than one-fourth of an inch. A broad fringe results 
in great swelling, often suppuration, and after healing an unnecessary deformity 
due to redundant tissue. This removal of the mucous layer should be done with 
especial thoroughness on the under surface of the penis. 
In amputating the foreskin the scissors must, of course, not be permitted to cut 
the glans itself. Some oedema, perhaps ecchymosis, occurs at the point of cocaine 
injection. 
Free evacuation of the bowels and bromide-of-camphor pills at night will assist 
in preventing painful erections and oozing of blood during sleep. The wound is 
re-dressed in three or four days, and should be entirely healed in eight or ten 
days. The patient need not keep his bed at all, though the healing is more rapid 
if he does so. 
External Urethrotomy.—In this operation, also called perineal and 
membranous urethrotomy, the membranous urethra is opened by an 
incision through the perineum. It is thus performed : 
The patient is anaesthetized, the rectum evacuated, the bladder irri- 
gated, and five or six ounces of an antiseptic fluid injected into it; the 
perineum and posterior scrotal wall shaved and cleansed. The legs and 
thighs are held fully and symmetrically flexed (lithotomy position); a 
grooved staff introduced until its point enters the prostatic urethra and 
its shaft stands about vertically, is firmly held by an assistant, who keeps 
the beak well against the under surface of the symphysis. The scrotum 
is held upward, exposing the perineum; with a long-bladed, full-bellied 
scalpel the surgeon makes a vertical incision an inch long through the 
skin in the median line, its lower end about an inch above the anus. The 
lubricated fore finger of the left hand is then passed into the rectum and 
rests against the staff* where it enters the prostate. The knife is then 
turned edge upward and held horizontally; its point is entered at the 
lower end of the skin incision, and is thus passed through the perineal 
tissues till the point enters the groove of the staff; this movement can 
be guided by the finger in the rectum. The knife, still held horizontally 
and its point kept in the groove, is then drawn upward until its shaft 
reaches the upper end of the skin incision ; by this movement the mem- 
branous urethra is freely opened. The knife is then drawn horizontally 
toward the operator and away from the staff*, cutting its way out. A 
grooved director or stiff probe is then passed into the incision to the staff, 
and along the groove of the latter into the bladder. The staff and finger 
in the rectum are now withdrawn, and the fore finger of the right hand 
worms its way through the wound, along the director as a guide, into 
the bladder. A drainage-tube is passed about an inch into the bladder (if 
of rubber, it should be held in position by a silk suture through the cut 
edges of the skin): the bladder, urethra, and wound are well irrigated; 
iodoform gauze is lightly packed around the tube, and a T-bandage 
applied. 
Perineal Section.—This differs from the operation just described, OPERATIONS. 
513 
external urethrotomy, in that it is made without a guiding staff: the 
term is applied to the operation in cases of stricture too tight to permit 
the introduction of a'guide through the membranous urethra. A stall* is, 
however, passed as far as possible, since its point aids the surgeon in 
locating the position of the membranous urethra. 
It is identical with the former operation, except that a narrow knife with long 
blade is used, and that this knife, instead of being passed through the perineum 
into the groove of the staff, is steadily and cautiously passed, guided by the finger 
in the rectum, to the point where the staff ought to be—that is, to the apex of the 
prostate. The knife is withdrawn and a director or probe introduced into the 
wound and the prostatic urethra. The space between this director and the end of 
the staff is the location of the membranous urethra, which should then be carefully 
opened with a knife, and a full-sized sound passed into the bladder before the 
director is withdrawn. The operation is by no means so simple as the description; 
indeed, it is apt to be one of the most trying and delicate procedures in urinary 
surgery. 
Suprapubic Cystotomy.—The patient is anaesthetized, the rectum 
emptied; pubes, scrotum, and perineum are shaved and cleansed; the 
bladder is well irrigated; five to eight ounces of warm antiseptic fluid 
are injected and retained by a light rubber band around the penis. The 
patient is placed in the Trendelenburg position—that is, on an inclined 
plane which raises the hips twelve to eighteen inches above the shoulders. 
An incision three inches long, its lower end half an inch below the upper 
border of the symphysis, is then made in the median line down to the 
recti muscles; these are separated by the handle of the scalpel and kept 
apart by blunt retractors. The operator’s finger is then passed down the 
posterior surface of the symphysis to the bladder and presses the pre- 
vesical fat upward toward the peritoneal fold. A tenaculum seizes the 
muscular wall of the bladder near the upper angle of the wound ; a 
sharp-pointed knife is then plunged through the bladder-wall near the 
symphysis, making a cut half an inch long, and is quickly followed by 
the finger before the contained fluid escapes. After the calculus, vesical 
or prostatic tumor has been removed and the bladder irrigated, a large 
rubber drain with lateral openings at the end is passed through to the 
base of the bladder and stitched to the skin : around this iodoform gauze 
is lightly packed, and the upper end of the wound is closed by sutures 
passing through skin and recti muscles. The usual dressings are applied 
around the tube. 
Many modifications of this procedure are used in special cases: sometimes the 
bladder is distended with air instead of water—an excellent plan when the blad- 
der is weakened by ulceration, since the danger of rupture is less. Some surgeons 
still distend the rectum by means of an oblong rubber bag (Peterson’s); some 
stitch the cut edges of the bladder to the edges of the skin wound. While none 
of these measures are desirable as routine practice, yet it is usually wise (especi- 
ally if the urine be foul) to make a perineal urethrotomy, insert a metal drain 
(Watson’s or Belfield’s), and close the supervening bladder wound with catgut 
sutures, leaving a strip of iodoform gauze in the wound above the bladder. The 
danger of septic infection and peritonitis is greatly diminished by this method. 
Nephrotomy.—The kidney may be reached by an incision through 
the loin or through the abdominal wall: the former is, for obvious 
reasons, the incision of choice, and the latter is rarely necessary. 
The lumbar incision should begin at the outer margin of the sacro- 
lumbalis muscle (two to four inches from the spinous process) about half 
an inch below the last rib, and it should be extended parallel with this 514 
GENITO-URINARY SURGERY. 
rib for three or more inches, cutting down to the muscle. The muscular 
layers are separated down to the strong layer of lumbar fascia underly- 
ing the transversalis muscle : when this is divided in the line of the 
superficial incision, the perirenal fat is dis- 
covered, moving up and down synchronously 
with the respiratory movements of the dia- 
phragm. The finger and thumb passed into 
the wound detect the kidney as a solid body 
which should be drawn into the incision and 
exposed by dissection of its fatty envelope. 
The organ being firmly grasped with the left 
hand, a sharp, narrow knife is passed from 
the convex border to the pelvis of the kidney 
and withdrawn, making an incision suffi- 
ciently large to permit the entrance of the 
operator’s fore finger. A calculus is detected 
and removed or a flexible probe passed down 
the ureter : after the manipulations in the 
pelvis are concluded, the edges of the kidney 
wound are compressed for a minute or two, 
whereby hemorrhage is usually completely 
arrested. A rubber drain is stitched in the 
lower angle of the wound, which is lightly 
packed with iodoform gauze, the remainder 
of the incision being closed by deep and superficial sutures. 
Fig. 222. 
Incisions for exposing the kidney: 
L, longitudinal or vertical incis- 
ion ; K, transverse incision; T, 
Konig’s incision (Stimson). 
The one defect in the lumbar incision is the limited space afforded: to remedy 
this various procedures have been adopted. Thus, a pillow is placed under the 
opposite loin, the usual method; an assistant may firmly press upon the patient’s 
abdomen so as to force the kidney into the wound. A great increase in space and 
convenience of manipulation can be secured by making a second incision, which 
shall extend from the middle of the first to the iliac crest—the so-called combined 
incision. 
Since the twelfth rib is found to be rudimentary in about 5 per cent, of cases, 
it is very important that the surgeon count the patient’s ribs before making the incision, 
since the knife entering half an inch below the eleventh rib would open the pleural 
cavity and cause a probably fatal collapse of the lung—an accident which has 
actually occurred. 
Nephrectomy.—The combined incision already described affords the 
space necessary for removal of the kidney unless this organ be greatly 
enlarged, in which case nephrectomy should be done by laparotomy. When 
the combined lumbar incision has been made the fingers are gently in- 
sinuated around the ends and convex borders of the kidney, so as to 
separate it completely from its fatty capsule, leaving the renal vessels 
and ureter as a pedicle. When possible, the artery should be ligated 
separately, though sometimes it is necessary to tie all the vessels en 
masse: stout silk ligatures are passed around the vessels by means of 
large aneurism needles. Ligature en masse should be reinforced by a 
clamp to be left in position for forty-eight hours. During the entire 
manipulation great care should be taken not to pull strongly upon the 
renal vessels. The ureter should be ligated separately, and its stump 
sterilized with carbolic acid. The wound should be closed, drained, and 
dressed in the usual aseptic manner. DISORDERS OF INSEMINATION. 
515 
Spermato-cystotomy.—The seminal vesicles, when the seat of 
acute suppuration, can often be emptied into the urethra by gentle 
pressure with the finger in the rectum; in some cases acute distention 
of the vesicles with pus has been treated by incision from the perineum, 
the knife being guided by a finger in the rectum. 
Chronic suppuration of the vesicles is likewise usually amenable to 
treatment by repeated milking or stripping of these organs, as already 
described. In some cases, however, persistent treatment by this method 
fails : in two such instances the writer has opened a chronically distended 
vesicle in the following way : The anaesthetized patient is laid upon the 
affected side, the rectum emptied, cleansed, and blocked with iodoform 
gauze about four inches above the anus. The sphincters are then 
stretched by the thumbs, and the anus kept patent by retractors. A 
longitudinal incision half an inch long is made through the mucous 
membrane of the rectum over the lower end of the distended vesicle; 
this sac is then gently drawrn into the wound by means of an aneurism 
needle and incised; its cavity is explored and cleansed with a probe. 
In one case two small calculi, blocking the ejaculatory duct, were found 
and removed. Possibly this operation may be often useful in cases of 
chronic spermato-cystitis which have resisted less radical treatment. 
DISORDERS OF INSEMINATION. 
The deposit of motile spermatozoa in the vagina—insemination—is the 
function of the male in reproduction. Imperfections in this function are 
known clinically as impotence and sterility: the former means inability 
to copulate, the latter (when not due to impotence) implies the absence 
of moving spermatozoa from the semen. 
Impotence. 
Inability on the part of the male to copulate, when not the result 
of malformation, is due to one of two phenomena—premature ejacula- 
tion or imperfect rigidity of the penis. Both are often exhibited by the 
same patient, the habit of early ejaculation having existed for some time 
before erectile power fails. 
The pathology of this condition is explained by a consideration 
of the process of normal copulation. The enlargement and hardening 
of the penis, constituting normal erection, is due to the distention of 
the cavernous and spongy bodies with blood : this distention is brought 
about by the dilatation of the penile arteries and the constriction of the 
venous exits; the latter effect is produced by the contraction of the 
perineal and penile muscles innervated by branches of the second sacral 
nerve proceeding from the genital centre in the lumbar cord. 
This genital centre responds to a stimulus from either of two sources—the 
brain or the nerve-endings distributed in the penis from prostate to glans. Erec- 
tion, then, may be induced through excitement of this centre by influences from 
above—sexual thoughts or congestion of the upper cord (as in the priapism which 
often follows fracture of the cervical vertebrae), or by influences from the periph- 
ery, such as friction of the glans, irritation of the same by a tight prepuce, con- 
gestion of the prostatic urethra by a distended bladder (morning erections) or by 516 
GENITO-URINARY SURGERY. 
gonorrhoeal inflammation. The genital centre may also be directly stimulated by 
certain substances taken into the blood—cantharides, muscarine, alcohol. 
Feebleness or complete absence of erection may therefore be due to any 
one of the following factors : 
(1) Inhibition of the genital centre from the brain, induced by emo- 
tion—fear, anxiety, disgust, grief; such impotence is transient, ceasing 
when a normal emotional balance is restored. 
(2) Diseases of the spinal cord, such as locomotor ataxia. 
(3) Exhaustion of the genital centre by excessive activity, whether by 
intercourse or by masturbation. 
(4) Depression of the genital centre through a vice of nutrition, such 
as diabetes mellitus and chronic alcoholism. 
(5) Disturbances of nerve-endings in the genital organs—especially 
prostate and testicles—due to inflammation in these organs. This is 
clinically the commonest cause of impotence. 
Ejaculation of semen is accomplished by the same nervous apparatus when 
stimulated to a higher degree, usually through friction of the peripheral nerves in 
the glans. It consists of a contraction of the genital muscles, beginning with the 
fibres on the broad ligament and seminal vesicles, and continuing through the 
prostate and perineal compressors. Premature ejaculation, like imperfect erection, 
may be caused by a mental influence or by disease of the peripheral nerves. 
Clinically, the most frequent cause of impotence is chronic inflamma- 
tion of the prostate and appendages; and this results either from gonor- 
rhoeal infection of these organs or from sexual excess, whether in venery 
or in masturbation. 
The subject of this chronic inflammation often complains of pain in the sacrum 
(which he thinks indicates kidney disease), less frequently in the suprapubic region, 
perineum, rectum, testicles, and penis: the last-named organ is often cold and 
shrunken. Anxiety and despondency are marked; the patient frequently inspects 
the external organs, notes and broods upon every trivial deviation from what he 
considers the normal condition ; he is sure that one testicle hangs down too far, etc. 
The subject complaining of impotence should be carefully interro- 
gated as to previous gonorrhoea and sexual excess; then a digital exam- 
ination of testicles, prostate, and seminal vesicles should be made, the 
latter organs being gently pressed or “ milked.” This milking process 
often causes a discharge of milky-looking fluid from the meatus, in which 
the microscope reveals leucocytes, fatty epithelium, and sometimes 
motionless spermatozoa. 
Diagnosis.—Two questions must be answered: (1) Does impotence 
really exist f and (2) To what is it due f The patient’s experience can 
alone answer the first question ; the physician must estimate how much 
of the failure is due to emotional disturbance, for in some cases a man 
fails in intercourse simply because, having as a boy masturbated, lie is 
terrified by the perusal of the quack circulars and pamphlets so widely 
distributed. 
If imperfect sexual power seems likely to exist, it must next be decided to 
which of the recognized causes (above mentioned) this shall he attributed by the 
methods of examination already described. 
Treatment.—The treatment of impotence will naturally depend 
upon the cause : when due to diabetes, etc., the treatment of the sexual 
deficiency is that of the general condition. When such morbid states 
have been occluded, the treatment is mental and local. STFAULITY. 
517 
In some cases the emotional is the chief element: in nearly all it must be con- 
sidered, for even when there is an organic cause, the mental despondency aggra- 
vates the trouble. The chief remedy for the emotional element is faith in an early 
recovery; and this should be encouraged when such faith is warranted. The next 
emotional remedy is prohibition of all sexual dalliance, not merely of intercourse; 
for the perversity of human nature makes this a valuable stimulus to the sexual 
desire and capacity, and such patients not infrequently confess after a time that 
they have successfully violated the injunction. 
The local treatment is that for chronic inflammation of the prostate 
and appendages already described—“ milking ” of these organs, the 
passage of larger sounds, deep injections of hydrastin or weak silver- 
nitrate solution, alternating hot and cold sponging of the perineum and 
external genitals, and pills of camphor monobromide. In cases of 
exhaustion of the genital centre by sexual excess, rest from all sexual 
excitement is imperative; mental and physical diversion is important; 
strychnine, phosphorus, and belladonna are sometimes useful. 
The prognosis varies with two factors—the cause of the impotence 
and the age of the patient: the most favorable cases are those due to 
gonorrhoea and in young or middle-aged men; these usually recover 
completely in a few months. In cases of impotence due to sexual excess 
the prognosis is less favorable. 
Treatment must usually be continued for several months. 
Sterility. 
In the majority of unfruitful marriages the cause of sterility is located 
in the female; in a minority—perhaps 10 per cent.—in the male. 
Failure to fertilize the female may be due either to inability to eject the 
seminal fluid into the vagina (impotence) or to the absence of motile 
spermatozoa from that fluid (sterility proper): the latter condition may 
coexist with perfect power to copulate. In some cases no spermatozoa 
whatever are found in the semen—a condition known as azoospermia, 
and due either to lack of secreting cells in the testicles or to obstruction 
in the seminal canals. The fibroid or eunuchoid testicle usually produces 
no perfect spermatozoa, and testicles retained in the abdomen or groin 
are apt to be sterile. Obstructions to the passage of spermatozoa may 
be due to malformations or to inflammatory exudates in epididymis or 
ejaculatory duct (from gonorrhoea) or urethra (stricture). 
Sometimes the semen contains perfectly formed spermatozoa, which are, how- 
ever, even when first emitted, nearly or quite motionless : this absence of motion, 
entailing sterility, is due to a catarrhal condition in some part of the seminal tubes, 
especially the prostate and seminal vesicles; for the spermatozoa, motionless in 
the testicle, are normally aroused to movement by contact with the prostatic secre- 
tion ; when this is abnormal from chronic inflammation of the prostatic follicles, 
the spermatozoa may exhibit feeble movements or none at all. 
The treatment of sterility is determined by the cause : if examina- 
tion of the freshly-passed semen (received in a condom) shows no sper- 
matozoa, treatment is useless unless a chronic double epididymis exist, 
in which case persistent massage of the indurated tissues with mercurial 
ointment may be made. If spermatozoa be present, but motionless, the 
usual treatment for chronic inflammation of prostate and vesicles should 
be instituted. 518 
GENITO- URINAR Y SURGER Y. 
These occur in two ways—as nocturnal emissions, caused by contrac- 
tions of the genital muscles, and as spermatorrhoea due to the muscular 
contractions incident to defecation and micturition. 
Seminal emissions with the nocturnal orgasm, occurring during sleep 
and preceded by an erotic dream, are experienced by healthy, continent 
men at intervals of ten to thirty days: when not followed by languor 
and fatigue, they may be considered compatible with health. 
Emissions occurring at short intervals, and followed by lassitude and 
sacral pain, usually indicate abnormal excitement of the genital tract. 
They are common in boys and young men who have practised mastur- 
bation for a long time; also in those who indulge in sexual excitement 
without intercourse ; and they often result from the extension of a gon- 
orrhoeal inflammation to the prostate and seminal vesicles. 
Involuntary Seminal Discharges. 
Frequent emissions cause great anxiety and despondency in youths who have 
practised masturbation and have been led to believe that nocturnal emissions 
inevitably cause early loss of virility. 
Treatment.—The patient should be assured that involuntary emis- 
sions do not indicate destruction of the genital organs, and that the 
majority of boys have at some time practised masturbation. He should 
be instructed to avoid dalliance and ungratified sexual excitement. Con- 
stipation and alcohol must be carefully avoided. 
Monobromide of camphor, two grains night and morning, will usually diminish 
the excitability of the genital centre in the cord, and thereby lengthen the inter- 
vals between nocturnal emissions. Local measures which reduce the congestion of 
the prostate and seminal vesicles, already mentioned, should be used—large, cold 
sounds, milking of the parts, deep injections of hydrastin, the hot and cold 
douche, etc. 
Spermatorrhoea is the term designating the involuntary escape of 
seminal fluid, without orgasm or even erotic thoughts: it occurs 
almost always at the close of defecation or micturition. In the strict 
sense, which implies that the escaping fluid contains spermatozoa, this 
is a relatively rare condition, except as the result of straining at stool 
when the seminal vesicles are full, and this may happen to the healthiest 
man. The escape from the meatus of a few drops of milky fluid during 
defecation is, however, common : this fluid is usually prostatic secretion 
containing no spermatozoa, and the condition should be called prostator- 
rhcea rather than spermatorrhoea. Whether it contain spermatozoa or 
not, the habitual appearance of this fluid indicates a catarrhal state of 
the genital organs, which should be treated by the measures prescribed 
for chronic inflammation of the prostate and vesicles. 
Pain during ejaculation and an admixture of blood with the semen 
are sometimes observed as the result of chronic inflammation of the 
prostate and vesicles. CHAPTER XII. 
CHANCROID OR VENEREAL ULCER. 
Roswell Park, M. D. 
Since the day of John Hunter and his pupils, who confused the three 
totally different and so-called venereal diseases, pathologists have drawn 
a sharp and distinct line between chancre, which is simply the initial sore 
of syphilis (vide p. 187, Vol. I.), and chancroid or venereal ulcer, which 
is a distinctly local lesion, often destructive, but never followed by con- 
stitutional disease, save of septicsemic or pysemic type. It is found 
usually upon the genitals, most commonly about the foreskin, glans, and 
vulva, but may be met with anywhere upon the body where infection 
may have occurred. It is distinctly auto-inoculable, in which respect 
it differs from chancre. 
Although no distinct micro-organism has yet been identified as its active cause, 
there is good reason to think that there is a specific virus of some kind which 
causes it. Its course is characterized by local inflammation and tissue-destruction, 
without changes in the vessel-walls or surrounding induration. 
Chancroid begins, even in twenty-four hours, as a red point or 
papule, which is quickly converted into a pustule, and then an ulcer. 
The borders of this ulcer enlarge, its depth increases, until after a few 
days it forms a more or less deep, often undermined excavation, 
irregular in contour, discharging grayish purulent material. In this 
respect it differs also from chancre, whose natural discharge is more 
like serum. In other words, chancroid is essentially destructive, chancre 
constructive, since the latter forms a new growth which ordinarily has 
little or no discharge. When the necrosis of chancroid becomes exten- 
sive and tends to spread rapidly, the ulcer is spoken of as phagedenic. 
This tendency to rapid local gangrene is the combined result, probably, 
of virulence of virus and lowered local or constitutional tissue-resistance. 
It is consequently most often seen in alcoholics and prostitutes. In 
rare instances a surface as large as the hand may thus be rapidly 
destroyed, every particle of material thus sloughed being extremely 
infectious. In chancroids of the mild variety the discharge may dry 
upon their surfaces and scabs or crusts result, beneath which, when 
detached, the characteristic ulcer is present. 
Under proper treatment this foul ulcer is converted into an ordinary 
granulating surface, which heals by cicatrization, as described on p. 94, 
Yok I. 
Chancroidal Bubo.—Infection—-by propagation along the lymphat- 
ics—of the inguinal nodes is very common, and, since the infection is 
almost always a mixed one, suppuration is quite frequent. 520 
CHANCROID OR VENEREAL ULCER. 
It is necessary to emphasize that the pus of a suppurating chancroidal bubo is 
often as infectious as the discharge from the original sore; hence it is wise to 
exercise great caution. Moreover, the edges of the local incision should be 
promptly cauterized, that they, too, may not become linear chancroids. Phagedena 
shows itself here as well as about the genitals proper, and differs only in that 
it makes the case more serious of its kind. Chancroidal bubo may, however, 
subside without abscess-formation, phagocytic activity being in such event most 
lively and most kindly. The signs of suppuration are those incident to pus- 
formation anywhere near the surface. When pus is present its early evacuation 
is called for. 
Diagnosis.—Chancroid is most likely to be confounded with chancre 
and herpes preputialis. Chancroid has no period of incubation. 
Destruction commences promptly after infection, so that ordinarily 
within twenty-four hours macroscopic evidence thereof may be observed, 
and within two or three days the sore has attained distinct size and 
shape. Apparent exceptions to this occur only when it is concealed 
from sight, as when within the urethra, vagina, or rectum, or beneath a 
tight foreskin. The history is then an important factor in diagnosis— 
i. e. the time which has elapsed between exposure and the commence- 
ment or discovery of the ulcer. Confrontation, when possible, may help 
in obscure cases: this means a careful examination of the partner in the 
sexual act from whom the disease is supposed to have been acquired. 
Chancroid lacks the characteristic induration of chancre, which has a 
distinct period of incubation, never less than ten days, usually twenty. 
(Vide p. 187, Vol. I.) Only when it has been mistreated or irritated 
will there be anything like condensation of tissue; usually the reverse 
obtains and oedema is common. 
Herpes is a distinctly vesicular lesion, usually accompanied by pain 
and burning. The vesicles may be confluent, but never tend to destruc- 
tion per se, nor to spread. 
Chancroid. 
Chancre. 
Herpes. 
Local ulcer. 
First local sign of a con- 
stitutional disease. 
Local neurosis. 
A distinctly venereal in- 
Usually a venereal infec- 
May be non - venereal, 
fection. 
tion. 
from friction, irrita- 
tion, uncleanliness, etc. 
No incubation; lesion 
noticed within few 
days. 
Incubation from ten to 
seventy days before first 
lymphatic induration. 
No incubation. 
Commences as, and re- 
Commences as a papule, 
Commences as a crop of 
mains, an ulcer. 
or occasionally an ero- 
sion. This may ulce- 
rate later. 
vesicles. 
Usually multiple. 
Usually single. 
Multiple and occurring 
in crops or series. 
Secretion purulent and 
abundant. 
Secretion slight and se- 
rous or bloody. 
Little or no secretion. 
May occur again and 
As a rule, only occurs 
Patients who once have 
again. 
once in same patient. 
it are frequently sub- 
ject to it. 
Auto-inoculable. 
Not auto-inoculable. 
Not inoculable. 
Phagedena frequent. 
Phagedenic action very 
rare. 
Never. 
Buboes in about 65 per 
Bubonic enlargement 
Lymphatics rarely in- 
cent, of cases. 
Buboes usually suppu- 
rate. 
nearly always. 
Buboes, as a rule, do not 
suppurate. 
volved. EXTRA-GENITAL CHANCROID. 
521 
Prognosis.—Except in the most debilitated and dissipated, in whom 
phagedena may prove fatal, recovery always occurs, but often at the 
expense of considerable destruction of tissue and disfiguring scars. 
Treatment.—In mild cases—i. e. those showing but little destruc- 
tive tendency—absolute cleanliness and the use of hydrogen peroxide, 
followed by local use of such antiseptics as iodoform, aristol, loretin, 
etc., or even of calomel, will usually prove sufficient. If the ulcer 
manifest any tendency to spread, it should be cleansed, cocainized, and 
then cauterized with nitric acid or the actual cautery, after which it 
should be treated kindly to encourage granulation. This holds good 
still more in phagedenic cases, which may call for general anaesthesia, 
with the use of scissors and sharp spoon, followed by cauterization of 
every particle of raw or diseased surface. 
Widespread phagedena is much more rare now than formerly. Cases 
which are extensive do best when submitted to continuous immersion 
of the hips in a sitz-bath as hot as can be tolerated. All aggravated 
cases call for invigorating and tonic measures, laxatives, improved 
nutrition, and sometimes for stimulants. 
Suppurating buboes should be incised, often curetted, and thoroughly 
swabbed out with pure carbolic acid, then packed lightly with loretin 
gauze and allowed to close by granulation. Virulent cases will be accom- 
panied by sloughing of so much tissue that it is best to remove all 
sloughs with scissors to save time. Here even stronger caustics will be 
called for. Phimosis often complicates chancroid, and will necessitate 
circumcision or incision along the dorsum of the prepuce, with such 
attention to the parts thus exposed as their condition may require. 
Mixed chancre, or the combination of the two lesions, has been 
treated of on p. 190 of Vol. I., to which the reader is referred. 
Extra-genital chancroid may occur upon any portion of the body, 
but is more rare than extra-genital chancre. It is characterized by the 
same peculiarities as pertain to the venereal sores already described. CHAPTER XIII. 
SURGICAL DISEASES AND INJURIES OF THE FEMALE 
REPRODUCTIVE ORGANS. 
James H. Etheridge, M. D. 
Malformations. 
The congenital malformations of the female genital tract which 
require operative treatment are not common. They are exclusively of 
the nature of stenosis or atresia of some part of the tract, and the 
symptoms which they cause are due either to the retention of menstrual 
fluid or to the obstruction which they cause to copulation or delivery. 
The cause of these malformations is unknown. Most of them seem 
to be simply instances of arrested development, while others seem due 
to inflammatory processes during foetal life. 
One of the most common malformations is the double vagina, often 
accompanied by a double uterus. This condition usually causes no 
symptoms, and is discovered accidentally during a vaginal examination 
made for some other reason. If the uterus and vagina be double and 
one vagina show an atresia, we find fairly normal menstruation accom- 
panied by the signs of vaginal atresia—namely, pain, pelvic tumor due 
to retention of menstrual fluids, etc. Rarely, when the vagina is double 
and the uterus single, the septum between the vaginae becomes an 
obstacle to delivery and must be divided. 
Atresia of the vagina is a more or less complete defect in the 
development of the vagina, so that there is no communication between 
the uterus and the external genitalia. It varies in extent from an 
imperforate hymen to a complete absence of the vagina. The lower 
part of the vagina is more frequently lacking than the upper. The 
external genitalia are usually normally developed. Usually there are 
no symptoms until puberty, and then only when the ovaries, tubes, and 
uterus are normally developed or the only abnormality is a double uterus. 
When ovulation begins the woman experiences the same general physical 
and mental disturbances observed during menstruation in a normal 
woman. Pain is present and persists during the intervals between the 
periods. It increases in severity as time goes on, and is due to the ten- 
sion caused by the retained menstrual fluids. If the upper part of the 
vagina is developed, the blood collects there, forming a hsematocolpos. 
As the amount increases the uterus and later the tubes are distended, 
causing hsematometra and haematosalpinx. The distended uterus can be 
felt as a smooth, round, usually fluctuating tumor lying low in the 
median line of the pelvis. Sometimes the haematosalpinx can also be 
palpated. Pressure on the bladder and rectum causes functional dis- 
522 THE VULVA. 
523 
turbances, incontinence, retention, and tenesmus. The pains in the legs 
and the oedema sometimes seen are also due to pressure. Direct examina- 
tion shows a normal vulva, with no vagina or one developed in its lower 
part only. A sound in the bladder can be brought close to the finger 
in the rectum. Bimanual palpation through the rectum and the 
abdominal walls shows hsematocolpos, haematometra, and hsematosalpinx. 
The treatment in cases where the defect is merely an imperforate 
hymen is simple—a crucial incision, after slow removal of the retained 
fluids through a trocar or small incision. If the defect is more exten- 
sive, the areolar tissue between the bladder and rectum should be care- 
fully incised and the dissection be carried deep enough to open the 
Inematocolpos. If possible, the raw surfaces of the dissection should 
be covered by drawing their edges together and suturing them, or by the 
use of grafts of mucous membrane or flaps from the labia minora. If 
none of these plans are possible, glass plugs should be inserted and 
retained until epidermization has occurred from the periphery. 
When the entire vagina or the main part of it is lacking, no attempt to make 
a vagina should be made. The patient should be castrated and the retained fluid 
aspirated after the abdomen is open. Rectal puncture of the haematometra is too 
dangerous, because of the liability of infection from the rectum. 
Practically, no malformation of the uterus requiring surgical care occurs, 
except those cases of dysmenorrhcea due to narrowness of the cervical canal. These 
are easily treated by dilatation, either with or without previous incision of the 
cervix. The uterine cavity is usually curetted at the same time. 
Inflammatory processes about the vulva are common, and are 
due to widely varying causes—gonococci, pus-cocci, irritants from the 
urine, especially sugar, oxyuris, oidium albicans, and other parasites. 
The symptoms vary in intensity with the severity of the process. 
Local pain, sometimes some of the other constitutional disturbances 
which often accompany local infective processes, discharge, often puru- 
lent or fetid, inguinal adenitis, are usually present. There may be 
added the symptoms of vaginitis, endometritis, salpingitis, or even pel- 
vic peritonitis, which in some cases, especially those due to gonorrhoea, 
occur by extension. Dysuria may appear, due to the extension to the 
urethral mucous membrane. In the more chronic cases, especially those 
due to diabetes, the process is essentially an eczema, and its symptoms 
are such as occur with eczema elsewhere. 
The Vulva. 
The recognition of the case is important, as it indicates the form of treatment. 
The gonorrhoeal cases will be readily discovered by microscopical examination of 
the secretion stained with watery solution of fuchsin or methyl blue. ( Vide Yol. 
I. Chap. XI.) Cases due to vaginal fistulae are readily recognized. Diabetic 
cases are discovered by an examination of the urine. 
Cases due to infection are treated by rest in bed, if possible, with frequent local 
baths and douches of hot antiseptic solution, and any constitutional treatment 
which the case may require. Cases due to fistulae are cured by curretting the 
fistulae. Eczema should be treated with a zinc ointment or diachylon ointment, 
with 5 per cent, each of ichthyol and salicylic acid, and at the same time any local 
or general disturbance should be treated. 
Oedema of the vulva occurs sometimes in the course of pregnancy as 
the result of local circulatory disturbances, and frequently in the course 524 
THE FEMALE REPRODUCTIVE ORGANS. 
of anasarca from whatever cause. Because of the looseness of the tissue 
the swelling is often extreme. 
Treatment must be directed to the cause. Locally, multiple 
incisions may be made if gangrene of the parts threatens or if the swell- 
ing be so great as to hinder urination. Very great care is necessary to 
avoid infection, which is favored both by the local and general condi- 
tion. 
The glands of Bartholin, about the size of a bean, situated deeply on 
the inner side of the labia majora, with ducts opening about the middle 
of the sides of the vulva, are frequently the seat of inflammatory pro- 
cess, oftenest gonorrhoeal. It is in these glands that the gonococci fre- 
quently lodge and lie latent even for a long time. When the infection 
is severe abscesses are liable to develop in the glands. They cause 
Fig. 223. 
Abscess of gland of Bartholin. 
severe local pain, swelling of the labia and neighboring parts, painful 
defecation and urination, more or less severe fever, and constitutional 
disturbances. Fluctuation appears later, first on the inner side of the 
labium. If untreated, extensive necrosis is liable to result, and severe 
consequences following on healing, because of the cicatricial contractions. 
The dangers of septicsemia and pyaemia are present here as with other 
abscesses (Fig. 223). 
Treatment consists of free incision and antiseptic irrigation, fol- 
lowed by hot, wet boric- or carbolic-acid dressings. 
Cysts of the glands of Bartholin result from inflammatory occlu- 
sion of the excretory ducts. They may be singular or multilocular, vary 
in size from a nut to an egg, smooth, ovoid, with viscous contents, color- 
less unless mixed with blood. They cause few symptoms other than dis- 
comfort while walking or during copulation, unless the cysts suppurate, THE VULVA. 
525 
as they not infrequently do, when the symptoms of an abscess appear. 
Hernia into the labium must not be mistaken for a cyst. 
The best treatment is complete removal of the cyst by dissection. 
Pozzi first removes the contents of the cyst through a trocar, and after 
irrigation fills the cavity with paraffin of a low melting-point. After 
hardening the paraffin by cold he dissects out the sac. 
A variety of tumors occur about the vulva. Varicose veins com- 
plicate pregnancy rather frequently, and may on rupture cause serious, 
even fatal, hemorrhage. Subcutaneous rupture of such a varix may 
occur, and the resulting hsematoma be large enough to be an obstacle to 
Fig. 224. 
Condylomata of the vulva. 
delivery. The varieose veins should be treated by compression combined 
with an abdominal supporter. If an hsematoma develop, it should be 
left alone if small, but if large, because of the great danger of its 
becoming infected, it should be incised and the bleeding vessel found 
and tied if possible. If this cannot be done, the hemorrhage should be 
controlled by a tampon of iodoform gauze. The most careful asepsis is 
necessary. 
Condylomcita due to gonorrhoea are common. They are cauliflower- 
like excrescences on the skin and mucous membrane, pale red or wine 
color, and often very large. There is an abundant foul discharge, often 
hemorrhagic (Fig. 224). Pain may be severe. 526 
THE FEMALE REPRODUCTIVE ORGANS. 
Treatment consists of removal, under cocaine, with the scissors, 
followed by cauterization of the base. After-treatment is frequent hot 
antiseptic sitz-baths. 
Epithelioma of the vulva is rare. It develops oftenest from the 
groove between the greater and lesser labia, next frequently from the 
clitoris and meatus. It extends rapidly to the inguinal lymph-nodes. 
The symptoms are minimal at first, but later, when the carcinoma 
has attained some size, the pain becomes severe, the secretion abundant, 
and bladder and rectum disturbances appear as the result of exten- 
sion to these organs. Whenever the diagnosis is doubtful a microscopi- 
cal examination of a bit of the tissue should be made. The only cura- 
tive treatment is early and complete removal, but the prospects of per- 
manent recovery are poor. Palliative treatment consists in the use of 
the curette or actual cautery in order to lessen the secretion, and local 
antiseptic dressings and baths. Morphine ad libitum for the pain should 
be used. 
Fibromata, myo-fibromata, lipomata, neuromata, and other tumors 
occur about the vulva, but they are rare. Their symptoms are due to 
their size and location, and may be severe enough to necessitate removal. 
The Perineum. 
Laceration of the perineum occurs most frequently during labor. 
Sometimes it is due to the removal per vaginam, either by operation or 
the process of nature, of large uterine tumors, especially submucous 
myo-fibromata. Rarely the laceration is due to direct trauma. Lacera- 
tion during parturition is favored by any condition which renders the peri- 
neum less elastic. These are particularly advanced age—i. e. past thirty 
years at the time of the first delivery—and chronic vaginal and peri- 
vaginal inflammation, most commonly gonorrhoeal or syphilitic. Lace- 
ration is favored also by excessive development of the foetal head, its 
descent in an abnormal position, or its too rapid descent. 
The laceration usually starts in the median line or very close to it, at the pos- 
terior commissure of the vagina or close to the posterior column, and continues on 
one or both sides of this. According to the depth of the tear, lacerations are 
divided into two classes, the incomplete and the complete. In the former class are 
included all cases in which the sphincter ani is not torn through. These cases 
vary from the almost inevitable laceration of the mucous membrane of the vagina 
to almost complete division of the anal sphincter. The distance to which these 
tears pass up the posterior wall of the vagina also varies greatly. The complete 
lacerations are those in which the sphincter ani is torn through, and usually the 
tear extends some distance up the anterior wall of the rectum. 
Before proceeding to a description of the symptoms and treatment of this con- 
dition it would be well to recall somewhat briefly something of the anatomy and 
function of the perineum. The perineal body is not a mere inert mass of connec- 
tive tissue, but is a wedge-shaped body consisting of muscles, connective tissue, 
fat, vessels, and nerves. The muscles entering into its formation are the sphincter 
ani, constrictor vagina?, transversus perinei, and the levator ani. The most import- 
ant function of this body is the support of the pelvic organs. When it is 
destroyed by laceration or rendered incapable of performing its duty because of 
local or general causes, as senile involution, malnutrition, and the like, more or 
less extensive downward displacement of the pelvic organs must occur, unless 
these organs are held in place by pelvic adhesions or their prolapse is prevented 
by maintaining the recumbent position and leading a life of minimal activity. 
The symptoms do not usually appear until some time has elapsed, THE PERINEUM. 
527 
and their severity is not always in direct proportion to the extent of the 
laceration. A laceration in one woman may cause no especial disturb- 
ance, while in another a tear of the same size or smaller can cause unen- 
durable suffering. With the descent of the vagina and uterus there may 
be a sensation of gaping of the vulva, the feeling as if the pelvic con- 
tents were falling out. Later, when the prolapsed parts protrude through 
the vulva, there is acute pain from the inflammation of mucous mem- 
brane caused by trauma of some sort. Incontinence of urine or incom- 
plete evacuation of the bladder lead in time to cystitis. Vesical and 
rectal tenesmus are common. Although copulation is not obstructed, ste- 
rility not infrequently results. When the laceration is complete incon- 
tinence of gas and liquid fieces is added. In addition to these local 
symptoms there is a great variety of reflex disturbances and general 
impairment of health. 
On direct examination the vulvar orifice appears lengthened poste- 
riorly. The site of the laceration is marked by a glistening white scar, 
which by its contraction has caused a puckering of the bordering parts. 
Varying with the case there may be cystocele, rectocele, or prolapse of 
the uterus. In complete cases the vagina and rectum are no longer 
separated, and at the lower end of the remains of the recto-vaginal sep- 
tum one often sees the hypertrophied rectal mucous membrane projecting 
downward like a polyp. The posterior column of the vagina may be 
isolated by the laceration passing to either side of it. 
When a fresh laceration is left to itself, cicatricial bands, irregularly 
connecting the borders of the tear, are formed. The edges are drawn 
upward by the levator ani, and the ends of the divided sphincter ani are 
often marked by slight depressions on either side. 
All practitioners are now agreed that in all cases, except where the 
laceration is very superficial, the tear should be sutured at once. 
Although cases of spontaneous cure occur—and some authors claim that this 
may happen even in cases of complete laceration—the chances of recovery are too 
small and the possible results of delay are too serious to warrant leaving a cure to 
nature, especially as the primary operation adds no danger at the puerperal period. 
These lacerations should be treated by exactly the same methods which are used 
in the treatment of lacerated wounds of other parts of the body. Corresponding 
parts should be united by sutures which are passed deeply enough to secure union 
of the deeper parts and in sufficient numbers to secure accurate approximation. 
This procedure is often difficult because of the swollen, oedematous condition of 
the parts, the abundant hemorrhage, and the exhausted and excited condition of 
the patient. 
The less extensive lacerations will require skin sutures only. When 
more extensive a line of sutures must be carried up to the vagina, and 
in complete cases rectal sutures are necessary. It must never be for- 
gotten that the purpose of the operation is the union of the deeper and 
muscular parts rather than of the skin and mucous membrane. 
The suture material varies according to the individual preferences of 
the operator, but probably silkworm gut is more generally used than 
any other material, and it always proves most satisfactory. 
The after-treatment consists in the careful protection of the wound 
surface from urine by the use of the catheter. After a few days 
voluntary urination may be allowed, and the parts afterward carefully 
washed with antiseptic solution. The vulva and perineum should be 528 
THE FEMALE REPRODUCTIVE ORGANS. 
kept covered with moist antiseptic dressing. The bowels should be 
kept free by laxatives when necessary. The patient should remain in 
bed for at least two weeks, and throughout the entire time the thighs 
should be tied together. 
A large number of operations have been devised for the late treat- 
ment of lacerations of the perineum, but the purpose of all is the same 
and the principles underlying them are similar. 
Although the operations for the complete and the incomplete lacera- 
tions are essentially the same, it is customary and convenient to describe 
them separately. 
Operations for Incomplete Lacerations. 
Before the operation the patient should be given mild laxatives for 
several days until the bowels are free from all hard faeces. At the same 
time care must be taken to avoid hypercatharsis. The vagina should 
be douched daily for several days. 
The patient, after being anaesthetized, should be placed in the lithot- 
omy position before a window or strong light. After the usual anti- 
septic preparation of the parts, two triangular areas are denuded by 
Fro. 225. 
Lacerated perineum : surfaces denuded and stitches in position (Thomas and Mund6). 
the scalpel or scissors, the surface to. be denuded being held tense by for- 
ceps or threads. The base line'of the triangles lies in the median line 
and extends from the cutaneous margin to the highest point of the bulg- 
ing of the rectum. The third angle of the triangle is on the inner side 
of the great labium, about midway between the anus and the meatus. 
After these two triangles are denuded of the cicatricial tissue which 
covers them, the hemorrhage is checked by ligatures if necessary, though 
it is rarely that they are demanded. The sutures are then passed from OPERATIONS FOR INCOMPLETE LACERATIONS. 
529 
points on one side of the median line to the corresponding points on the 
other side. The sutures must be passed deeply, and care must be taken 
to avoid passing the needles into the rectum (Fig. 225). The sutures 
near the rectum are entirely buried, while those uniting the antero-lateral 
parts of the triangle are exposed in the median line of the vagina. The 
sutures should be passed with a straight or curved round needle, entered 
about a quarter of an inch from the border of the denuded surface, and 
the sutures should be about a third of an inch distant from each other. 
After the sutures are tied the parts are cleansed and dusted with an 
antiseptic powder. The after-treatment is the same as with the primary 
operations. 
Emmet’s Operation.—The area lying between the posterior commis- 
sure, the lowest caruncle of the hymen, and the crest of the rectocele 
is denuded on either side. The 
anterior and the lateral borders 
of the denuded area on each side 
are united by sutures which are \ 
passed deeply. The remaining 
Fig. 227. 
Fig. 226. 
Emmet’s new operation for lacerated peri- 
neum. 
Emmet’s operation for lacerated perineum. 
portions of the lateral borders are united to each other. The resulting 
line of union is Y-shaped, the stem being in the median line, and an arm 
passing up each side into the vagina (Figs. 226 and 227). 530 
THE FEMALE REPRODUCTIVE ORGANS. 
Tait’s (or the Flap-splitting-) Operation.—The posterior wall of 
the vagina is stretched forward by a rectal tampon and by the fingers in the 
rectum. The labia are drawn tense by the assistants and sharp-pointed 
scissors are inserted in the median line, midway between the posterior 
commissure and the anus. The recto-vaginal septum is split to the 
depth of one-half or three-quarters of an inch, and for the same dis- 
tance on either side of the median line. From the ends of this incision 
another, about one-half an inch deep, is carried up on each side to the 
anterior border of the cicatrix. The anterior flap is drawn forward by 
Fig. 229. 
Fig. 228. 
Flap-splitting operation for incomplete 
laceration of the perineum. 
Flap-splitting operation for lacerated perineum: appear- 
ance of wound and introduction of sutures for both 
varieties (Thomas and Mund<i). 
tenacula, and the resulting rectangular surface is closed by sutures 
passed from one side to corresponding points on the other (Figs. 228 
and 229). 
Doleris' operation for incomplete laceration of the perineum varies 
a little from the flap-splitting operations so commonly in vogue in one 
important particular. The upper stitches traverse the under surface 
of the flap, thus drawing the latter completely into the wound and 
making it constitute a portion of the body of the perineum. 
Fig. 230 represents the line of initial incision made with the knife 
or scissors. 
Fig. 231 shows the dissection of the mucous-membrane surface from 
the posterior vaginal wall by means of the fingers. 
Fig. 232 indicates the line of introduction of the sutures, a portion 
of which are carried through the flap. 
Fig. 233 presents the lower half of the wound closed. OPERATIONS FOR INCOMPLETE LACERATIONS. 
531 
Fig. 234 shows the resection of the redundant vaginal mucous 
membrane. 
Fig. 235 represents the completed operation. 
Fig. 231. 
Fig. 230. 
Doleris’ perineorrhaphy, a. 
Doleris’ perineorrhaphy, b. 
Duke’s Method of Perineorrhaphy.—The most recent operation 
for closing an incomplete laceration of the perineum is that offered by 
Fig. 232. 
Doleris’ perineorrhaphy, c 
Alexander Duke of Dublin, who sent the following description and 
illustration to the writer in 1892 : 
“ I wish,” he said, “ to bring before the notice of my gynecological 
brethren an operation I have designed for the restoration of a lacerated 532 
THE FEMALE REPRODUCTIVE ORGANS. 
perineum, easy of performance, and which will, when properly executed, 
form a good perineal floor and, I might almost say, practically a 
perineal body. The patient, having been prepared by the usual pre- 
Fig. 233. 
Doleris’ perineorrhaphy, d. 
liminary steps required for the old operation, when under the influence 
of an anaesthetic is placed in the lithotomy position ; the left index finger 
being introduced almost its entire length into the rectum, a long straight 
double-edged bistoury is made to pierce the tissues in front of the anus 
Fig. 234. 
Fig. 235. 
Doleris’ perineorrhaphy, e. 
Doleris’ perineorrhaphy, /. 
at right angles to the vulva, and, guided by the finger in the rectum, is 
made to penetrate the septum for two and a half inches upward, the 
incision being enlarged laterally to two inches as the knife is withdrawn. OPERATIONS FOR INCOMPLETE LACERATIONS. 
533 
“ The patient is then turned on her side, and on the points of the 
incision being pressed together a lozenge-shaped opening will be seen; 
and when all sutures required have been introduced and are properly 
adjusted and approximated the two cut surfaces are brought into direct 
apposition. The sutures are introduced by a strong cycle-shaped needle, 
with eye near the point, mounted on a handle, strong silver wire being 
the suture preferred. 
“ The needle is introduced at the edge of the incision, and, guided by 
a finger in the rectum, is made to travel under the cut surface to its full 
depth above, describing the arc of a circle; and on the point of the 
needle appearing directly opposite it is threaded with suture and drawn 
through. On the ends of this being drawn together with the fingers a 
good idea can be formed of how many additional stitches may be required. 
When all considered necessary have been in- 
serted and approximated, being first passed 
through a perforation in leaden plate (see illus- 
tration), a finger of each hand passed into the 
rectum and vagina will at once recognize the 
gain in thickness of septum, the external tissue 
being pushed fully an inch forward from the 
anus and forming a thick and solid perineal 
body. 
“ The incision being a deep one, on union 
taking place between the raw surfaces a con- 
siderable amount of support must be afforded 
in cases where a pessary is required or where 
there is much tendency to prolapse of uterus or 
vaginal walls. My experience of the operation 
has satisfied me with the results, and, there 
being no loss of tissue whatever, should the ope- 
ration fail it cannot add any difficulty to a sub- 
sequent one. 
“ Even should the perineum be lacerated to 
the verge of the anus, what I describe can be 
done. I find that leaving the sutures for ten 
days is generally sufficient; but if I am in doubt 
as to the union being strong, I cut the wire, but 
leave it in situ for a day or two longer, thus 
affording some support and relieving the strain 
on the edges of the suture-holes; and I also 
support the parts by long strips of adhesive 
plaster carried from hip to hip over new peri- 
neum. The wire should be stout and not too 
tightly twisted. 
u The advantages of my plan of operation 
are briefly these: 
“1. The simplest of performances as yet proposed; no danger of 
hemorrhage, the surfaces when dry being brought together. 
“ 2. No danger of sepsis, as the incision is not open for the admis- 
sion of any discharge from either vagina or rectum during the healing 
process. 
Fig. 236. 
Duke’s operation, showing vari- 
ous stages. 534 
THE FEMALE REPRODUCTIVE ORGANS. 
“ 3. No loss of tissue, and consequently no harm done should the 
operation fail” (Fig. 236). 
The outlines of the denudations made in the operations suggested by 
Bischoff, Hegar, and Fritsch are presented in Fig. 237. The under- 
lying principle of each is apparent. 
Operations for Complete Laceration of the Perineum. 
Operations for complete lacerations are more difficult on account 
of the often considerable deformity resulting from the contraction of the 
scar-tissue, and because of the ready hemorrhage from the rectal mucous 
Fig. 237. 
Scheme of the outline of operations proposed by Emmet, Simon, Bischoff, Hegar, and Fritsch 
(Kelly). 
membrane. Moreover, unless the preparation of the patient has been 
most careful, an escape of faeces is apt to occur during the operation. 
Simon’s Operation.—The area of denudation is a symmetrical, somewhat 
butterfly-shaped figure. The following points are seized with the forceps: A point 
on the inner side of the great labium about its middle, This corresponds to the 
anterior tip of the new-formed perineum. A second point is near the border of 
the anus, corresponding to the end of the divided sphincter ani. A third point is 
the tip of the remaining portion of the recto-vaginal septum. Lines drawn 
between these points determine the lateral and the posterior borders of the denu- 
dation. 
The denudation is carried upward on the vaginal side of the septum to the 
highest point reached by the tear. From this point a curved line, with its con- 
cavity forward, is carried to the point on the labium majus. The resulting area 
of denudation should closely resemble the rawr surface at the time of the lacera- 
tion. The second step in the operation is the suturing, which may be done in sev- 
eral ways. Simon passed three sets of sutures—the vaginal, tied in the vagina and 
uniting, as do the others, symmetrical points; the rectal set is tied in the rectum, 
and then the skin sutures are passed. The sutures must be passed deeply, but care PERINEUM. 
535 
must be taken in passing the vaginal sutures to avoid making a recto-vaginal fistula. 
Martin recommends passing the sutures in one, two, or three layers, using a con- 
tinuous catgut suture. 
Emmet’s Operation.—The area of denudation is similar to Simon’s. 
The peculiarity of the operation is the method of passing the sutures. 
Using a handled needle, the first suture is entered about one-third of an 
inch external and posterior to the posterior margin of the denudation, 
and carried through the lower part of the remains of the recto-vaginal 
septum to a point exactly opposite. The purpose of this suture is to 
bring together the ends of the divided sphincter ani muscle. When 
Fig. 238. 
Tait’s operation for complete laceration of the perineum. 
tied it acts as a purse-string suture, and by thus closing the defect in the 
septum converts the complete into an incomplete laceration. The other 
sutures are passed as in the operation for incomplete laceration. 
Tait’s operation for complete laceration differs but little from that 
for the incomplete. The recto-vaginal septum is split to the depth of 
about half an inch. At each end of this incision others are made for- 
ward to the anterior border of the cicatrix, and backward just beyond 
the ends of the divided sphincter ani muscle. These three incisions 536 
THE FEMALE REPRODUCTIVE ORGANS. 
resemble somewhat a capital H. The vaginal flap is turned forward by 
tenacula, the rectal flap backward, exposing in this way a quadrangular 
bleeding surface. Sutures are passed from side to side ; the one nearest 
the rectum is passed first, taking care to pass it deeply enough to include 
the ends of the sphincter muscle (Figs. 238-241). 
Fig. 239. 
Tait’s operation for complete laceration of the perineum. 
The after-treatment of the patient is of great importance. The 
field of the operation should be carefully cleansed, dried thoroughly, dusted with 
boric acid, and covered with a dry dressing. The wound must be protected from 
the urine by catheterization. Should the patient pass urine voluntarily, it should 
be passed under a stream of warm sterilized water. The bowels must be kept con- 
fined for three or four days, and then moved by a gentle laxative, aided, if need be, 
by a warm enema, which must be given with care by the physician or nurse, who 
thoroughly understands the reasons for and necessity of great care. A movement 
of the bowels once in three days is desirable, and if they tend to move more fre- 
quently a little opium should be given. If the patient is troubled with gas in the 
intestines, a soft rectal tube may be passed carefully several times daily. The diet 
should be nourishing, and for the first week, at least, fluid. Another method of 
managing the bowels is to give a daily saline laxative. This line of treatment is 
especially commendable, for obvious reasons, in cases of complete laceration of the 
perineum. All foods which contain much waste or which readily ferment must be 
forbidden. The use of an intestinal antiseptic, such as salol, is to be recommended. 
If the temperature rise, the wound has probably become infected. This can easily 
happen, because of the difficulty of accurate approximation and the exposure of PERINEUM. 
537 
the wound to the bacteria-loaded faeces. The edges of the wound become red, 
oedematous, painful, and tender, and, unless the infection can be controlled, union 
Fig. 240. 
Tait’s operation for complete laceration of the perineum. 
Fig. 241. 
Flap-splitting operation for complete laceration of the perineum. 
to a greater or less extent will fail. Sometimes the trouble will end on the removal 
of one or two of the sutures. If union fail along the cutaneous surface, no serious 538 
THE FEMALE REPRODUCTIVE ORGANS. 
results follow, but if the failure is in the recto-vaginal septum, a more or less exten- 
sive fistula results and a secondary operation is necessary to close it. Simple 
cauterization is sufficient if the fistula is small, but if large the edges must be 
freshened and closed by sutures. A secondary operation should not be undertaken 
sooner than four weeks after the first one. 
The sutures may be removed on the tenth or twelfth day. The patient should 
not begin to walk sooner than eight or ten weeks after operation, and copulation 
must be forbidden for at least six months. 
The Uterus. 
Prolapse of the uterus and vagina is usually the result of injuries 
to the pelvic floor occurring during labor, laceration of the perineum, 
and stripping of the vagina from its relation to the surrounding parts; 
but in many cases it seems that this factor does not occur for years after 
delivery. Such accessory factors are—too early return to work after 
delivery, severe manual labor, malnutrition from whatever cause, and 
senility. Rarely cases of prolapse occur in young virgins after some 
violent effort. Some congenital weakness of the supports of the vagina 
and uterus is supposed to exist in these cases, and this supposition seems 
to be more probable because the families of such patients often show a 
large number of hernias. Occasionally senility causes prolapse in women 
who have never borne children. Retroflexion, retroversion, and hyper- 
trophy of the uterus predispose to prolapse. 
The prolapse may affect only a small portion of the vaginal wall or involve the 
entire vagina and uterus. Usually the prolapse affects first the lower portion of the 
anterior wall, and shortly afterward the posterior wall is similarly affected. The 
uterus depends into the concavity of the sacrum, and its long axis comes to lie 
nearly in the long axis of the vagina. When the bladder descends with the ante- 
rior wall, we have cystocele. When the rectum comes down, rectocele is formed. As 
the vaginal prolapse increases the uterus descends lower and lower until its neck 
appears outside the vulva. In other cases the mechanism is different. The pro- 
lapse affects the lowest part of the anterior wall first, then the highest part, then 
the uterus, and lastly the posterior wall from above downward. In other cases the 
process is exactly reversed. In rare cases the prolapse affects only the anterior or 
posterior fornix of the vagina, and an anterior or posterior enterocele results. 
Sometimes the uterus descends, pulling with it the vaginal walls from above down- 
ward. 
The uterus is rarely unaltered in shape, consistency, and weight. The cervix 
is usually elongated and hypertrophied. The body is enlarged. The cervical and 
corporeal mucous membrane is inflamed. The relations of the bladder, uterus, 
and rectum are changed in many ways and to many degrees. The peritoneum 
follows the uterus in its descent. 
The symptoms vary in kind and intensity. The patients complain 
of bearing-down sensations and of the feeling as if the viscera were fall- 
ing out. They easily tire on walking, and their gait is often peculiar. 
The symptoms of endometritis are often present. Function of the bladder 
and rectum is altered. If the cystocele is marked, cystitis from incom- 
plete evacuation of the bladder is frequent. Pain from erosions and 
inflammation of the prolapsed mucous membrane may be severe. 
The result of local examination varies with the case. In the lesser 
degrees the vaginal mucous membrane appears only when the patient 
bears down, the anterior wall usually appearing first. In the complete 
cases the hypertrophied cervix lies behind the prolapsed anterior vaginal 
wall. The mucous membrane is variously altered. There may be THE UTERUS. 
539 
inflammation or ulceration, or the character of the mucous membrane 
can gradually change until it resembles skin. 
Treatment consists in general tonic with rest and massage. These, 
combined with a proper pessary or tampon, with astringent douches, will 
be sufficient in many cases. 
The operations for cure for this condition are of three sorts—those 
which improve the supports of the uterus lying below it, those which 
shorten the uterine ligaments or add other supports to them, and those 
which remove the uterus. The first class of operations includes perineor- 
rhaphy and colporrhaphy, many variations of which have been described. 
The perineorrhaphy is described in the section treating of lacerations of 
the perineum. The Golporrhaphy has for its purpose the narrowing of 
the vaginal canal. It may be made separately or in connection with a 
perineorrhaphy. The different operations vary in details only. 
An area is denuded on the posterior wall varying in shape from tri- 
angular to oval, and in size with the degree of the prolapse. Sym- 
metrical points on each side of the median line are sutured. Care must 
be taken to secure accurate approximation, using one or more layers of 
sutures as may be necessary. Martin denudes two long areas on each 
side of the median line, and closes each denudation by a continuous 
suture in layers. Neugebauer denudes two areas similar in shape and 
size, one on the anterior and one on the posterior wall, and unites them 
to each other, making a band across the vagina. 
Operations of the second class include the Alexander operation—i. e. 
shortening the round ligaments and ventro-jixation. These operations 
are rarely sufficient in themselves, but do well in combination with 
plastic operations on the vagina and perineum. 
Fig. 242. 
Alexander’s operation (a) (after Cleveland). 
Alexander’s operation is briefly as follows : Incisions are made on 
either side, exposing the external inguinal ring. The round ligament 
is next isolated. After replacing the uterus by the sound or by 540 
THE FEMALE REPRODUCTIVE ORGANS. 
bimanual manipulation the ligaments are drawn outward about three 
inches. A suture is passed through the upper end of the external pil- 
Fig. 243. 
Alexander’s operation (b) (after Cleveland). 
lar of the ring, then through the ligament, and then through the inter- 
nal pillar and tied. The lower portion of the ligament is treated by 
Clement Cleveland of New York in a way original with him. It offers 
the best results known to the writer, and he thus describes it. 
“ At this point I practise a modification of my own, which saves an inch or 
more of the ligament and, as it seems to me, secures a better prospect of success. 
Fig. 244. 
Alexander’s operation (c) (after Cleveland). 
A ligature-carrier (Fig. 243), made sharp and delicate for the purpose, is passed 
at the lower end of the incision under the fascia and out on the mons, at a point 
an inch or more below the pubic spine (Fig. 242). The carrier is then opened a 
little in order to make the canal sufficiently large for the passage of the ligament 
and to stretch the fascia slightly. A loop of silkworm gut or other material is 
then placed in the grasp of the carrier, and the instrument is drawn back with this LACERATION OF THE CERVIX. 
541 
loop into the incision (Fig. 243). A loop of the end of the ligament is then placed 
in the loop of silkworm gut (Fig. 243), and the latter drawn back with the ligature 
through the small opening in the mons (Fig. 244). While an assistant holds the 
ends of the ligament quite taut the sutures in the incision are then tied, and, 
lastly, the suture is passed through the integument and ligament at the point of 
exit of the latter on the mons, then tied, and the excess of ligament is cut away 
(Fig. 245). The same process is repeated on the other side. If the operation have 
Fig. 245. 
Alexander’s operation (d) (after Cleveland). 
taken a good deal of time or there have been rough handling of the tissues and liga- 
ment, a few strands of silkworm gut are placed under the ligaments in the canal 
as drainage. A dressing of gauze wet with a solution of 1 : 3000 bichloride is 
placed over the wounds, with pads of sterilized gauze and cotton above it, all 
being secured by a double spica bandage firmly applied. The patient is kept in 
bed for three weeks, Liquid food is given for the first few days, and after that, if 
no unpleasant symptoms have appeared, as generous a diet as is allowable to a 
patient kept in bed. The bowels are moved every other day.” 
Ventro-fixation consists in the median incision of the abdominal 
wall close to the pubes. The uterus is freed from adhesions and 
brought forward and upward. Sutures are then passed, either through 
the entire thickness of the abdominal wall, and through the serous and 
outer muscular coat of the uterus, or they may be passed in such a way 
that they are buried after closure of the skin incision. Before tying 
the sutures the parts of the uterine and parietal peritoneum which will 
come in contact should be scraped, in order to hasten the formation of 
adhesions. After leaving her bed the patient should wear a Hodge 
pessary for some time. 
Another method of surgical treatment, found satisfactory in most cases, is a 
combination of amputation of the cervix and an extensive anterior colporrhaphy. 
These operations are usually followed by a speedy uterine involution with its 
diminished weight, and by a substitution of anteversion of the uterus for retrover- 
sion. 
Laceration of the Cervix. 
Laceration of the cervix is almost always due to the passage 
through the cervix of a fully-developed foetus, though it has been known 
to occur with abortions at the third or fourth month. According to 
statistics by Munde, it occurs once in about every four deliveries, and 542 
THE FEMALE REPRODUCTIVE ORGANS. 
usually with the first child, but in more than half of the cases the 
laceration never causes any symptoms. The tear is usually bilateral, 
often unilateral, and then more frequently left than right. Sometimes 
it is multiple or stellate. (Plates XI. and XII.) 
In those cases in which the laceration of the cervix causes symptoms there is 
subinvolution of the cervix and uterus, hyperseinia of the uterine adnexa and liga- 
ments, predisposing all these contiguous parts to inflammation and leading event- 
ually to hyperplastic changes. The lips of the cervix roll outward, exposing the 
endocervical mucous membrane to trauma and the irritating action of the vaginal 
secretions, and in this way causing a chronic cervical catarrh. The scar-tissue 
which is formed obstructs the ducts of the glands, causing them to become cystic. 
The papillae become hypertrophied, and may be so much so as to resemble carci- 
noma. There is a profuse secretion of thick, glairy mucus, often tinged with blood 
from the granular surface, which bleeds on the slightest trauma. The catarrh often 
extends upward into the cavity of the uterus, where the endometritis often assumes 
a fungoid character. 
The symptoms vary greatly in intensity, and may be entirely lacking 
even with deep lacerations. The local symptoms are dull pain in the 
back, bearing-down sensation, pain in the ovarian regions, reflex pains in 
the thighs and back, leucorrhcea, menorrhagia and the consequences, 
sterility and habitual miscarriages. The general symptoms increase the 
longer the laceration exists, and take the form of a simple anaemia and 
various neurotic disturbances. The relation of cause and effect between 
the laceration of the cervix and the general symptoms described by 
Emmet is by no means clear. 
The diagnosis of laceration of the cervix is made by digital exam- 
ination of the cervix and by inspection through the speculum. Occa- 
sionally there will be a question as to whether a given case is simply an 
excessive development of the glands and papillae of the mucous membrane 
or an epithelioma. The question can be settled only by the microscope. 
Operation.—The patient, under anaesthesia—or without it if there 
is any contraindication, for this operation is not especially painful—is 
put in Sims’ or the lithotomy position. The cervix is drawn downward 
by bullet forceps or by sutures passed through the lips. The lower lip 
is denuded first from its tip to the angle, taking care to remove all of 
the scar-tissue. A narrow strip of mucous membrane about a quarter 
of an inch wide must be left in the median line to form the lining mem- 
brane of the future cervical canal.' :The anterior lip is treated in the 
same way, taking care to mate the.denudation o*i the anterior and pos- 
terior lips exactly alike in jsize. If the hemorrhage be trou- 
blesome, it may be checked by hctfe-wate'r or by a suture passed through 
the cervix above the angle of the tear. The sutures are passed through 
the entire thickness of both lips, the one nearest the angle being passed 
first. From two to four sutures on each side are usually required. 
After tying the suture a douche is given and the patient is put to bed, 
where she is kept for at least one week. If any discharge appear, an 
antiseptic douche should be given once or twice daily. The sutures are 
left in place two or three weeks. 
Myo-fibromata of the Uterus. 
The most common of the tumors of the uterus is the so-called fibroid, 
or, more properly, myo-fibroma. It consists of bundles of non-striated PLATE XL 
Granular Erosion of Cervix. 
Cystic Degeneration after Laceration. 
Deep Stellate Laceration 
Stellate Laceration with Ectropium 
and Cystic Disease. 
Crescentic Laceration with 
Erosion of one Lip. 
Deep Destructive Laceration 
up to Inner Os. 
LACERATIONS OF CERVIX. PLATE XU. 
Unilateral Laceration beyond 
Vaginal Insertion. 
Stellate Fissure with Erosion. 
Double Laceration with Erosion. 
Double Laceration beyond 
Vaginal Junction. 
Bilateral Laceration, Great Erosion and 
Cicatricial Induration. 
Cystic Disease Implanted on Lacerated 
Cervix, Simulating Cauliflower Growth. 
LACERATIONS OF CERVIX. MYO-FIBROMATA OF THE UTERUS. 
543 
muscles arranged in various directions, together with a varying amount 
of fibrous tissue, which is arranged mostly about the larger vessels, but 
also between the muscle-bundles. The tumors are, in a way, circum- 
scribed hypertrophy of the uterine wall. ( Vide p. 417, Vol. I.) 
The more abundant the fibrous tissue, the harder the tumor. The smaller 
tumors show a concentric arrangement about a single centre, while the larger 
tumors show several centres. The vascular supply is often abundant; in fact, the 
number of the vessels may be so great that the tumor can be spoken of as a 
teleangeiectatic or cavernous fibroma. The number of the tumors varies up to 
forty or fifty, and the size to even 172 pounds (78 kilos, Orth). The different 
tumors in the same uterus also vary in size. The most common site is the poste- 
rior wall, then the anterior, the fundus, and lastly the cervix. The cervical fibro- 
myomata make up about 8 per cent, of the total, and are especially apt to form 
polypi. 
The fibro-myomata developing from the body of the uterus are classi- 
fied according to their point of origin into three classes—the interstitial, 
developing in the thickness of the wall, 65 per cent.; the submucous, 
10 per cent.; and the subserous, 25 per cent. The interstitial tumors, 
because they can receive vessels from all sides, grow more rapidly and 
to greater size than the other forms. Their connection with the sur- 
rounding parts is so loose that they can usually be shelled out of their 
capsule very easily. The surface is smooth or lobulated according as 
they develop from one or several centres. 
The submucous forms occur oftenest at the fundus, and project to a greater or 
less extent into the cavity of the uterus. They may be sessile or pedunculated. 
The latter may be entirely detached from the wall and be expelled spontaneously. 
They are usually small, but they may reach the size of a child’s head. They are 
never lobulated, but their form may be much altered by pressure. 
The subserous forms are sessile or pedunculated. The length and thickness of 
the pedicle vary, and, like the pedicle of the submucous fibroid, may be divided 
and the tumor be detached from its point of origin. In exceptional cases, where 
there have been no adhesions formed previous to division of the pedicle, the tumor 
becomes a free body in the abdominal cavity. Usually, however, there are numer- 
ous adhesions, so that the tumor is attached to some other abdominal organ—a 
condition which may cause curious diagnostic difficulties. These adhesions are 
also important because of the complications which they may cause, such as inter- 
nal strangulation of the intestines, and because by increasing the blood-supply to 
the tumor they hasten its growth. 
Fibro-myomata are liable to a variety of secondary changes. Fatty degeneration, 
either localized or diffuse, is common, and can bring about a softening of the entire 
tumor into a puriform mass or lead to the formation of irregular cavities filled with 
a similar fluid. Calcification occurs most frequently in the subserous tumors of 
small size, though it may occur in tumors as large as an adult’s head. The calci- 
fication maybe diffuse, but it is usually in the form of irregular coral-like deposits, 
Sometimes only the peripheral parts are changed. Suppuration and gangrene occur, 
the latter especially in the polypoid form. (Edema is frequent, and affects espe- 
cially the connective tissue, converting it into a transparent, jelly-like mass. 
Important, but fortunately rare, is the change in the character of the tumor from 
benignant myo-fibroma to malignant, rapidly-growing sarcoma. The majority of 
the so-called fibro-cystomata of the uterus are the ordinary fibro-myomata altered by 
circulatory disturbances. Clear serous fluid can collect in interstices of the tissue 
or in lymph-vessels, forming even large cysts. These two forms may be distin- 
guished from each other by the fact that the distended lymph-vessels still show 
their endothelial lining. Very rarely cysts lined with cylindrical epithelium are 
formed in combination with fibroma. They are either detached portions of the 
glands of the mucous membrane of the uterus or are congenital epithelial 
dystopise. 
Very little can be said in regard to the etiology of these tumors. 544 
THE FEMALE REPRODUCTIVE ORGANS. 
They are never formed before puberty. They are most common between 
thirty and forty years ; more frequent in negroes than in whites. Nullip- 
arous women are more subject to them than others. Chronic endo- 
metritis and menstrual disorders favor their development. 
The symptoms are more influenced by the position of the tumor 
than by its size and numbers. Even large tumors may develop from the 
fundus without causing any symptoms, while small tumors situated low 
down on the anterior or posterior wall of the body of the uterus or in 
the cervix, especially when they develop into the broad ligaments, may 
cause serious symptoms because of the pressure which they exert upon 
the bladder, rectum, and the large vessels and nerves of the pelvis. 
Leucorrhoea, menorrhagia, and dysmenorrhoea are common. The uter- 
ine hemorrhages are often severe, and frequent enough to greatly debil- 
itate the patient, and may be so abundant as to cause death by exsan- 
guination. Pain is frequent and varies in location and intensity. There 
may be nothing more than a sensation of weight in the pelvis and bear- 
ing down, or it may amount to a severe sciatica. Uterine colic, expul- 
sion-pains similar to labor-pains, are common, when the tumor projects 
greatly into the uterine cavity. Disturbances in urination are common 
—dysuria, retention, and gradual dilatation of the bladder. In time 
cystitis develops, and later may lead to an ascending pyelo-nephritis. 
Pressure may be directly on the ureters leading to hydro-nephrosis on 
one or both sides. It is probable that many of the deaths which follow 
operations on uterine fibro-myomata are due to these secondary affections 
of the urinary tract. Pressure on the rectum causes rectal tenesmus, 
hemorrhoids, and constipation. 
The general health of the patient suffers from the loss of the fluids 
of the body by hemorrhage and the often profuse discharge; also from 
the toxaemia resulting from absorption from the urinary and intestinal 
tracts and from the pain and mental depression. 
The diagnosis of fibro-myomata of the uterus must be made by the 
physical examination, by vaginal, abdominal, and bimanual palpation. 
The tumor, unless small or in a very fat woman, is readily palpated, 
and its connection with the uterus usually readily demonstrated. The 
uterine sound, which must be carefully passed on account of the danger 
of its setting up a hemorrhage, shows that the uterine cavity is length- 
ened often to a very considerable degree. 
Differential diagnosis of myo-fibroma from pregnancy can usually be made by the 
common signs of pregnancy—amenorrhoea, the breast changes, etc.—but occasion- 
ally these signs fail to give a positive conclusion, and the patient must be watched 
for the positive signs of pregnancy. Differentiation from extra-uterine pregnancy 
is still more difficult and often impossible. In such a case the rule must be that 
if there are any reasonable grounds for suspecting extra-uterine pregnancy, lapa- 
rotomy must be done at once. Tumors due to pelvic cellulitis and hematocele are 
accompanied by signs of acute inflammation or by a history of such symptoms, 
and are usually readily distinguished from fibroma, but the differential diagnosis 
becomes impossible in cases of fibroma in uteri which are adherent and the adhe- 
sions the seat of acute inflammatory processes. Examination under ether may 
clear up the diagnosis in such cases. 
/Submucous fibroids are easily confused with incomplete abortions and endometritis. 
The history may aid in the cases. If not, microscopical examination of bits 
removed by the curette must decide. 
Prognosis as regards life is generally favorable, although the gen- MYO-FIBROMATA OF THE UTERUS. 
545 
eral health is often so impaired by the frequent loss of blood that slight 
ailments, such as bronchial or intestinal catarrh, may prove fatal. The 
danger of pyelo-nephritis must not be forgotten, and we must remember 
that cases of large abdominal tumor show signs of cardiac insufficiency 
due to fatty or interstitial changes in the myocardium. The tumor may 
become gangrenous along the course of its pedicle or it may suppurate. 
On the other hand, the tumors often atrophy on cessation of the uterine 
and ovarian functions. 
Palliative treatment is resorted to in the majority of cases, and 
especially in those where the symptoms are slight or the patient near 
the menopause. Many of the symptoms, such as pain, sciatica, consti- 
pation, vesical irritation, which result either from displacement of the 
uterus or its enlargement, are relieved by reposition of the uterus to its 
normal position and its permanent retention by the use of whatever 
pessary most completely fulfils the requirements. The hemorrhages are 
treated in various ways—by ergot, hydrastis canadensis, cannabis indica, 
gallic acid internally, and locally by styptics and tampons. If these 
means fail, the curette should be used. An intra-uterine electrode with 
the galvanic current is also used for this purpose. 
The curative treatment is medical, electrical, or surgical. 
Ergot given hypodermically or by mouth for many months cures not infre- 
quently the monolobular variety only. Mineral waters, especially those contain- 
ing the alkaline iodides and bromides, preparations of arsenic and phosphorus, 
and hydrastis canadenesis have all been used, and each has, in a certain number 
of cases, given positive results. 
Treatment by electrolysis requires currents of 80 to 250 milliamperes strength. A 
large electrode is applied to the abdomen, and the other pole is introduced into the 
uterine cavity or by puncture through the vagina or abdominal walls directly into 
the tumor. Each sitting lasts for from three to six minutes, and the sittings must 
be continued over several months. A certain number of cures are effected in 
this way. 
The surgical means used in the cure of fibroids vary greatly with 
the cases, but the operations may be divided into two classes—the 
vaginal and the abdominal. The majority of cases are treated by the 
former class. Fibroma of the cervix can usually be removed by simple 
incision of the capsule and enucleation with the finger or dissector. 
The hemorrhage is usually insignificant, but if severe can be controlled 
by pressure with a tampon or by the use of hot water. Operations for 
pedunculated fibroma of the body of the uterus must often be preceded 
by dilatation of the cervix in order to reach the tumor more easily. 
This may be done rapidly by Ilegar’s dilators, with or without bilateral 
division of the vaginal portion of the cervix with the scissors and of 
the fibres of the internal os with a bistoury. After dilatation of the 
cervix the removal of the tumor is usually easy. The tumor is first 
twisted a few turns about the long axis of the pedicle. After making 
certain, by examination through the abdominal walls, that the uterus 
has not been inverted, the pedicle is divided by scissors curved on the 
flat. The hemorrhage is usually slight, but if severe can be controlled 
by a tampon or by heat. The uterine cavity is douched with an anti- 
septic solution, and the cervix, if divided, is sutured as in operations 
for lacerations of the cervix. The use of the chain and wire 6craseur 
has been largely abandoned, because the danger for which they were 546 
TIIE FEMALE REPRODUCTIVE ORGANS. 
introduced—namely, hemorrhage—has been found to be minimal, and 
they brought with them dangers greater than the one they sought to 
avoid. It is quite impossible to perfectly control the amount of tissue 
included in the loop, and perforation of the uterus has happened several 
times, even in the hands of experienced operators. 
Submucous fibroids, including the interstitial tumors which are close 
to the mucosa, are treated as follows : The cervix, if not already dilated, 
must be dilated as described above. The tumor is seized with volsellum 
forceps; the mucous membrane is incised freely along the line where it 
is reflected from the uterine wall on the tumor. The tumor is now 
separated by the fingers, scalpel, or scissors from its capsule, and, with 
or without previous fragmentation, removed. 
The after-treatment is the same as already described. The dangers 
of the operation arc hemorrhage; perforation of the uterine wall, which 
is not a very serious accident if the operation is done with proper asep- 
tic care; inversion of the uterus—a favorable rather than an unpardon- 
able occurrence if it is recognized, as it facilitates the enucleation; 
and, lastly, septicaemia, which is to be avoided by the ordinary rules of 
aseptic surgery. In some cases where the tumor is large the cap- 
sule is incised, and without effort at enucleation the tumor is re- 
moved in pieces by morcellation, controlling the hemorrhage by 
forceps. 
Vaginal hysterectomy is employed in cases where the tumor does 
not exceed the size of the fist, when the hemorrhage threatens to be 
rapidly fatal, and when serious compression symptoms develop. In all 
other cases, where the tumor cannot be removed by any of the opera- 
tions already described, the patient is put in the lithotomy position and 
the vagina douched and scrubbed with antiseptics. The cervix is drawn 
forward so as to put the posterior wall of the vagina on the stretch, and 
a transverse incision made down to the peritoneum. Sutures are then 
passed in such a way as to unite the peritoneum to the posterior wall 
of the vagina and, at the same time, compress any vessels lying in the 
cellular tissue. If the Douglas cul-de-sac has been obliterated by 
adhesions, a second row of sutures may be necessary. 
The index finger is now inserted into the wound and the broad liga- 
ment passed forward. A curved needle with a heavy suture is entered 
in the lateral fornix about one inch from the angle of the wound, and 
carried deeply enough to pass above the lower branch of the uterine 
artery, and then brought out about one and a half inches from the point 
of insertion. The suture is then firmly tied, and the same thing done 
on the other side. The anterior fornix is now opened, and lateral 
incisions are made connecting this with the posterior incision. The 
bladder is carefully dissected from the uterus up to the peritoneum. 
The uterus is now turned backward and ligatures are passed through 
the broad ligament and tied. Usually the ligament is tied in three 
sections. After ligatures are tied in both broad ligaments, the ligaments 
are divided between the body of the uterus and the line of ligatures and 
the tumor removed. The parts are now sponged and freed from blood. 
The wound in the peritoneum may be closed, but it is not necessary. 
A gauze drain is inserted and the patient put to bed. The patient 
should be catheterized for a few days. The bowels, after being confined MYO-FIBROMATA OF THE UTERUS. 
547 
for a few days, should be moved by a mild laxative aided by a warm 
enema. Vaginal irrigation must be forbidden for a week or ten days 
(Fig. 246). 
The details of the operation vary with different operators, hut the method 
above described in brief is satisfactory. Some operators use forceps to prevent 
Fig. 246. 
Vaginal hysterectomy: forceps on left broad ligament. 
hemorrhage from the broad ligaments, leaving them in situ for forty-eight or 
seventy-two hours. 
The dangers of the operation are those common to all severe operations— 
shock, primary or secondary hemorrhage, and sepsis, plus the danger of injury to 
the ureters at the point where they lie close to the uterus. There is also some 
danger of opening the bladder. These dangers can be avoided by operating care- 
fully. 
Abdominal Myomectomy.—The following operations are done 
through the abdominal wall : After the customary antiseptic precau- 
tions the abdomen is opened in the median line and the tumor exposed. 
The capsule is freely incised and the tumor shelled out. The resulting 
cavity may be closed by deep sutures or, if thought necessary, can be 
drained into the vagina. The tumors suitable for this method of operat- 
ing are the non-pedunculated subserous ones and those which have 
developed into the broad ligament, Pedunculated tumors are removed 
after separating any adhesions, dividing them between ligatures if 
necessary, and then division of the pedicle after ligating it. 
Abdominal hysterectomy may be complete or may stop at supra- 
vaginal amputation of the cervix uteri. Each method has its advocates. 
Results seem to be equally satisfactory in both methods. In the former 
less detail of technique is necessary. 
After both operations atrophic changes follow in the vaginal walls, making it 
difficult sometimes to state which operation was performed. It will thus be seen 
that the alleged advantage of the incomplete over the complete operation—viz. 
that the stump of the remaining cervix serves as a keystone to the vaginal arch— 
is not a good argument. Increased chances of infection through the cervical canal 548 
THE FEMALE REPRODUCTIVE ORGANS. 
are imputed to the more complete operation by its opponents. It is found, however, 
that at times infection follows both operations. It is found also that both operations 
are performed at other times without any infection following. Hence, when infec- 
tion follows at all, it may fairly be attributed to some fault in operative technique. 
Dr. Eastman of Indianapolis advocated the best compromise between the two 
operations yet offered. He neither stops with the supravaginal amputation nor 
does he incise the vaginal vault. He enucleates the body of the remaining 
cervical stump from its investing membrane, and does not incise the vaginal tract 
at all. 
The abdomen being sufficiently opened to eventrate the tumor after 
severing adhesions requiring it, the first point to be settled is the method 
of securing the vascular supply to the tumor. The steps necessary to 
secure this end vary vastly. In some cases, where the broad ligaments 
are not split up by the growtli projecting into them, the procedure is 
simplicity itself. In other cases, where masses project from the sides of 
the tumor into the broad ligaments, the difficulty of securing haemostasis 
is rarely excelled in the whole range of surgery. The one point never 
to be lost sight of is the fact that the broad ligaments contain the ves- 
sels supplying the neoplasm. When the growth rides high and free in 
the abdomen and its pedicle is the cervix uteri, not increased in its 
dimensions, and the broad ligaments are comparatively flabby and 
relaxed, the simplest and speediest method of operating is to place a 
large snap-forceps at an angle of about forty-five degrees from the 
tumor, diagonally across the broad ligament down to the cervix, avoid- 
ing the ureter. The forceps will thus be made to pass from the upper 
part of the cervix upward and outward. It is better to place them thus 
than to place them parallel with, or transversely to, the axis of the tumor. 
To render the operation as nearly bloodless as possible it is necessary to 
adjust the forceps most carefully ; which means that they must be made 
to include the uterine artery. If the uterine artery be secured in the 
forceps, the ovarian artery will also be caught. It is necessary in adjust- 
ing the forceps to make the points of the jaws go clear down to the cer- 
vix. This is best done by making the tips of the jaws at first grasp the 
cervix a little, and then by a slight retraction of the handles let the jaws 
pass over the rounded contour of the cervix as they are closed. The 
bladder as well as the ureter must be avoided by the forceps. With 
both forceps adjusted the broad ligaments are cut from the tumor, with 
a knife or a heavy scissors, down to the junction of the cervix and for- 
ceps. By following down the cut closely with a folded towel, the out- 
flow of the residual blood from the tumor into the pelvis can be prevented, 
thus saving a certain amount of sponging. After both ligaments are 
severed the bladder is dissected from the cervix as speedily as possible. 
Then a flap of peritoneum is removed from the posterior surface of the 
tumor. The two dissections thus made, anteriorly and posteriorly, can 
have a crescentic or a straight border above as the operator desires. All 
that is necessary is to dissect off enough of the peritoneal membrane to 
supply an abundance of covering for the stump of the cervix. Then it 
will be found that naught but the cervix remains to be amputated. This 
being done, the uterus and the tumor are removed. 
The next step consists of dealing with the stump. Due caution 
against contaminating the peritoneum with the cervical secretions must 
be observed. After forcible dilatation of the canal with a large snap- MYO-FIBBOMATA OF THE UTERUS. 
549 
forceps its entire surface should be rendered satisfactorily aseptic by some 
approved means. There seems to be none superior to the free use of the 
Paquelin cautery. After its use the canal should be traversed by a piece 
of aseptic gauze crowded well down into the vagina with a sound, leav- 
ing the upper end of it flush with the top of the amputated cervix. 
This serves perfectly as a means of promptly draining away all wound- 
secretion through the vagina. It can be removed at the end of two or 
three days. 
Attention should now be paid to the haemostasis. Along the border 
of the amputated broad ligament, just outside the jaws of the large snap- 
forceps, the arteries can be picked up and secured. Silk or catgut can 
be used on a needle. The arteries can thus be secured singly with the 
use of a minimum amount of ligature without going outside of the folds 
of the broad ligament. This is a method better than to gather up the 
entire end of the broad ligament into a large bunch, which necessitates 
a longer and larger-sized piece of ligature, as is commonly done. This 
method of tying the arteries singly, as is done in a leg amputation, is 
surgically more correct. 
After securing the vessels in each broad ligament, all that remains 
to be done is to close the folds of peritoneum over the stump. To facil- 
itate this step, an Eastman staff can be introduced through the vagina 
into the Douglas cul-de-sac, and the seat of the operation can be thrust 
upward almost into the abdominal incision. This is a great improve- 
ment over the attempt to cover the stump as it lies at the bottom of the 
pelvic cavity. The edges of the peritoneal flap are now brought over 
the cervical stump and turned in, and the surfaces are closed by a con- 
tinuous Lembert suture of silk or catgut from one side to the other. At 
each angle of the wound the broad-ligament stump may be gathered in 
and covered completely out of sight. After completing the suturing 
there is naught but peritoneum to be seen, the field of the operation 
being completely extra-peritoneal. Nothing now remains but to close 
the abdominal incision. 
The length of time required to perform hysterectomy as herein described varies 
with the operator’s dexterity. Simple uncomplicated cases can be completed with 
ease in from fifteen to forty minutes. The amount of blood lost is the least attend- 
ant upon any of the suggested methods of performing abdominal hysterectomy. 
The more complicated cases are those wherein one or both broad ligaments are 
split up by projections into them of portions of the tumor. Where the projections 
are small they are easily managed; where they are large the whole tumor is so 
solidly bound down by the unyielding laminae of the ligaments that the difficulties 
encountered are enormous. 
The first step is to grasp the apex of the tumor with a large volsellum forceps 
and entrust it to an assistant, who draws the growth to one side as far as it can 
be drawn without tearing it. The chief danger lies in catching up the ureter, 
which may be forced out of its normal course to an astonishing extent by a pro- 
jecting mass of the tumor. A large double ligature is now thrust through the 
portion of the broad ligament outside of the intraligamentous mass. One portion 
is now tied close to the mass and divided, and the other portion is forced outward, 
tearing the ligament for an inch or more, and tied. The tied portion is now cut 
between the ligatures, when the mass can be raised somewhat out of its bed. 
Beneath the incision another double ligature can now be passed and tied similarly 
to the first one. Upon cutting through this second portion of the broad ligament 
the entire mass can be well raised out of its bed and the cervix on that side will 
be exposed. Sometimes liberation can be sufficiently accomplished after the use 
of one set of ligatures only. The opposite side can be treated in like manner. 550 
THE FEMALE REPRODUCTIVE ORGANS. 
Then the whole mass can be lifted up and the remaining steps of the operation 
performed as heretofore described. 
In these cases the bladder is sometimes greatly distorted, and a correspondingly 
greater amount of care is required to avoid injuring it. When it is opened it must 
be closed perfectly, care being taken to cover the wound with peritoneum. 
Another procedure now much in vogue is to make the cuff operation. After 
enucleating the tumor, its peritoneal covering is sewed into the lower angle of the 
abdominal incision, permitting drainage to be discharged externally. After filling 
the cavity of the peritoneal covering of the tumor with gauze and bringing it out- 
side, the abdominal wound is closed. Free drainage is thus secured, and as the 
cavity closes the amount of gauze is progressively decreased with successive dress- 
ings till the cavity is obliterated. 
Castration.—The idea of this operation is to bring about the meno- 
pause prematurely, for it has been observed that with the menopause 
myo-fibromata decrease in size and their symptoms become less, to nil. 
This operation is indicated when the hemorrhages are severe and the 
condition of the patient is such as to contraindicate the more hazardous 
operations. The operation is contraindicated in cases of large tumors, 
which are liable to suffer from circulatory disturbances secondary to the 
operation, and in cases where the pressure-symptoms are marked. 
A median incision is made at the level at which the ovaries are thought to lie, 
varying in cases with the size of the tumor. The ovaries are sought out and drawn 
to the incision. The pedicle is tied with a single ligature or in parts according to 
its thickness. The ovary is now removed, care being taken to get it all. If neces- 
sary, separate ligatures are now applied to the vessels in the stump. The stump 
is now cauterized with the thermo-cautery and dropped back. The other ovary is 
treated in the same way. In many cases this operation checks the hemorrhages at 
once or in a varying period of time. It checks the growth of the tumor and often 
causes marked diminution in its size. 
Cancer of the Uterus. 
Carcinoma of the uterus may commence in the body or in the cer- 
vix, but the latter is the usual point of origin. Some cancers begin in 
the cervical mucous membrane, either deeply in the form of nodules or 
merely in inflamed mucous membrane or from the surface. They are 
usually adeno-carcinomata or the ordinary medullary forms. Less fre- 
quently they produce papillary excrescences. The external os may 
escape for a considerable time, but sooner or later it and the entire 
vaginal portion are destroyed. The parametrium is involved early. A 
large number of carcinomata start from the vaginal surface of the vaginal 
portion. They are usually flat carcinomata, but when glands are present 
adeno-carcinoma may develop from them. 
These cancers early involve the vagina and perivaginal tissues, also the cervix 
and parametrium. The cervical cancers often lead to the formation of large ulcers, 
causing great destruction. An exact anatomical diagnosis in these cases may be 
difficult, even when post-mortem, hut usually examination of the lympli-nodules in- 
volved will remove every doubt. Carcinoma of the cervix also takes the form of 
cauliflower-like masses which may be so large as to completely fill the vagina. 
Carcinomata of the body of the uterus are much less common. They cause thick- 
ening of the uterine walls, with consequent enlargement of the uterus, either as a 
diffuse infiltration or as circumscribed nodules. Sections usually show an adenom- 
atous structure. The inner surface of the uterine wall is usually ulcerated, but 
they may be polypoid or papillary excrescences. The peritoneum is involved early, 
the cervix later. It is important to know what Sulig has recently demonstrated, 
that the extension of carcinoma along the lymph-channels is far beyond the micro- 
scopical limits of the tumor, and that in cases of carcinoma which seemed sharply CANCER OF TIIE UTERUS. 
551 
limited to the cervix bands of cancer-cells were found in the lymph-channels 
between the outer and middle muscular layers of the uterus almost to the orifice 
of the tubes. 
No more can be said of the etiology of cancer of the uterus than 
can be said of cancer elsewhere. It is a disease of adult life. It occurs 
more frequently among the poor than among the rich. It is much more- 
frequent in women who have borne children than in those who have not. 
Lacerations of the cervix predispose to carcinoma. Carcinoma of the 
uterus, metastatic to carcinoma of some remote organ, is very rare, but 
we do find carcinoma of the uterus due to extension from the rectum 
or bladder, although the extension is usually in other directions. We 
also find the so-called carcinoma by implantation—i. e. carcinoma of one 
lip of the cervix transferred by direct contact to the other lip—or car- 
cinoma of the cervix following carcinoma of the body of the uterus, 
with a band of normal tissue between. The existence of carcinoma by 
implantation is important, as it warns us to be careful in operating to 
avoid contact of a raw surface with the carcinomatous tissue. 
Symptoms.—Many patients suffer from pain, hemorrhage, and vaginal 
discharge even early in the course of the disease, while others remain 
free from any symptoms even with well-advanced carcinoma. The pain 
varies in character and intensity—pain in the back, colic-like pains, and 
peritoneal pains. The hemorrhage is at first merely an increase in the 
amount of the menstrual flow, or, if the patient be past the menopause, 
she usually thinks that the menstruations have returned. Later it 
becomes more frequent and abundant, and is readily excited by any 
trauma, cohabitation, defecation, or exertion. When necrosis of the 
superficial parts of the tumor occurs there is a most foul odor accom- 
panying the discharge. Anaemia, emaciation, and cachexia rapidly 
develop. The patients suffer from sleeplessness and anorexia. When 
the bladder and rectum become involved, symptoms of their disturbed 
functions are added. 
In well-advanced cases the diagnosis presents no difficulties, but in 
early cases, where the diagnosis is so very important, it can often be 
made only by the microscopical examination of a bit of tissue removed. 
The palliative treatment is, unfortunately, the one which must 
be most often employed, because most cases are not seen until too late for 
radical removal of the disease. If the uterus is fixed and immovable 
or if the pelvic lymph-nodes can be palpated, effort at radical removal 
is useless. If the pain, hemorrhage, or discharge demand treatment, 
the curette and cautery are our best means. All of the neoplasm which 
can be reached should be removed and the raw surface cauterized with 
the thermo-cautery or some chemical caustic, such as chloride of zinc, 
bromine, chromic acid, or perchloride of iron. The vagina is then 
tamponed with iodoform gauze. The curetting often relieves the pain 
as well as the hemorrhage and discharge. If it does not, morphine 
must, sooner or later, be resorted to. Tonics and nourishing diet are 
necessary, and any symptom which arises must be treated as seems best. 
The Only Operation for Radical Cure is Hysterectomy.—Ampu- 
tation of the cervix, in view of the recent pathological investigations, 
should not be attempted, even in the most favorable cases; for, although 
permanent cures do result from this operation, the dangers of recurrence 552 
THE FEMALE REPRODUCTIVE ORGANS. 
are too great. The best method of performing hysterectomy for carci- 
noma uteri is still a matter of dispute. Some operators prefer the 
vaginal and some the abdominal method, but probably the combination 
of the two is the best. Because of the danger of implantation of the 
carcinoma, all parts of the cancer which can be removed by the curette 
are removed, the base cauterized, and the mouth of the uterus closed 
by sutures or the cavity packed with gauze before any incision is made 
in the vagina. The vaginal wall is then divided by a circular incision 
far enough away from the cervix to be in healthy tissue. The dissection 
is then carried upward as far away from the uterus as possible, taking 
care not to injure the rectum or bladder. The next step in the opera- 
tion is opening the abdomen. The broad ligaments are then ligated as 
far away from the uterus as possible, and then divided. The reason 
for ligating the broad ligaments through the abdomen rather than 
through the vagina is because any extension of the carcinoma into the 
parametrium can be given a wider berth when operating through the 
abdomen than when operating through the vagina. The after-treatment 
is the same as after laparotomy for other purposes. 
The Ovary. 
Ovarian cysts are the most common neoplasms found in the ovaries, 
but before describing them brief mention should be made of cystic 
changes in the Graafian follicles. They occur especially in cases of 
chronic oophoritis or perioophoritis. The cysts commonly reach the 
size of a cherry or walnut, and are often multiple, while the larger ones 
—and they may be as large as the uterus at term—are usually single. 
The wall is thick, but with the smaller cysts it is often thin. There 
are no septa or remains of septa, no papillary excrescences, and the 
epithelial lining of the cysts is the cylindrical follicular epithelium, 
normal in shape or in the larger cysts flattened by pressure. The cyst- 
content is thin and serous and never stringy. It contains but few 
formed elements, but sometimes it is mixed with blood. A satisfactory 
explanation of the development of these cysts cannot as yet be given. 
{Vide Vol. I. Chap. XXVI.) Somewhat similar cysts occur in the 
corpus luteum. 
The cystomata or adeno-cystomata of the ovaries are true neoplasms. They 
occur on one or both sides, vary in size up to or beyond one hundred and 
forty pounds or more, may be single or multiple, and show many variations in the 
thickness and lining of their walls and the character of their contents. There 
may be many small cysts, but there are one or several large cysts with numerous 
small cysts. Daughter cysts often develop in the wall of the original cyst. 
Usually the cyst is multilocular, but some are originally unilocular, while others 
become so by the fusion of the separate cysts. The wall may be thin and trans- 
parent, but more frequently it is thick and strong. Adhesions to neighboring 
organs are common, and may be very extensive. The epithelium lining the cysts 
is usually cylindrical, but in large cysts may be flattened by pressure of the con- 
tents into cubical or even flat cells. Ciliated epithelium also occurs, but, as a rule, 
only in the so-called papillary cystoma—i. e. those in which Ave find papillary, 
cauliflower-like growths on the inner surface of the wall. These papillae vary in 
length, thickness, and the number of their branches. They may be few or so 
abundant as to entirely fill the cavity of the cyst or even rupture its walls. The 
outer surface of these cysts is usually free from papillae, but they are often present, 
and not rarely we find metastases of the papillae to the peritoneum. THE OVARY. 
553 
The contents of the cysts vary in specific gravity from 1010 to 1030, are alka- 
line, and show little tendency to coagulate. The consistency varies from thin, 
slimy, almost serous to thick jelly-like fluids. In some cases the fluid shows noth- 
ing to distinguish it from the fluid of an ascites. The color varies from clear and 
watery through green, yellow, red, to brown, and sometimes bloody or purulent. 
There is a large amount of cellular debris, red and white blood-corpuscles, epi- 
thelial cells of various kinds, colloid concretions, crystals of blood-pigments, and 
rarely cystin. Sometimes the presence of squamous epithelium, hair, teeth, or 
bones will show that the cyst is a dermoid. Chemical examination of the fluid 
shows albumen, metalbumen, and sometimes urea. (Vide Yol. I. p. 25.) 
The cysts usually develop toward the abdominal cavity (Fig. 247), 
making a pedicle of the ovarian ligament, the broad ligament, and often 
the tube also. This pedicle may be long and slender or short and thick. 
Fig. 247. 
Enormous ovarian cystoma (Rodenstein). 
Sometimes the cysts develop between the layers of the broad ligaments 
—intraligamentous cysts. There are numerous secondary changes to 
which these cysts are liable. Torsion of the pedicle is not rare, and hap- 
pens the more easily the longer the pedicle and the freer the surface of 
the cyst is from adhesions. When torsion occurs the veins of the pedi- 
cle are compressed : hypersemia, stasis, and necrosis result unless the 
blood-supply through the adhesions is sufficient to prevent it. If necro- 
sis occur, suppuration or gangrene develops from infection with micro- 
organisms. Fatty degeneration both of the epithelial lining and the 
cyst-wall is frequent. Calcification, either diffuse or localized, is com- 
mon, especially in the papillary form. Hemorrhage into the cyst is also 
common. Rupture of the cyst into the abdominal cavity occurs, leading 
to symptoms of acute peritonitis. If the cyst-contents are thin, they are 
completely absorbed, but the thicker they are the less complete is the 
absorption. Rarely the cysts rupture into the bladder or intestines. 
Sometimes sarcoma, and more frequently carcinoma, develop from cyst- 
walls. 
Entirely different from the form of cyst just described is the der- 
moid cyst which occurs with relative frequency in the ovaries. (Vide 554 
THE FEMALE REPRODUCTIVE ORGANS. 
Vol. I. p. 398.) Usually one, but sometimes both ovaries, are involved 
in the process. The dermoid tumors vary in size up to an adult head, 
rarely larger—are hard and generally globular. They contain masses 
of fat and hair, usually skin showing sebaceous follicles and sweat-glands, 
and often teeth, bones, and cartilage. They are not likely to grow rap- 
idly or reach any considerable size, but the danger of infection and sup- 
puration in the cyst and of torsion of its pedicle is sufficient to warrant 
removal whenever they are found. 
Practically, nothing positively is known about the etiology of this 
condition. The cysts rarely start before twenty or after fifty years of 
age, but they have been found in the new-born and as late as eighty 
years. They are more frequent in those who have not borne children 
than in those who have. 
The onset of symptoms is gradual. At first there are only indefinite 
reflex disturbances, due to congestion and stretching of the appendages. 
Sometimes, even very early, severe radiating pains on the diseased side 
appear with tenderness on pressure. In other cases the first symptoms 
may be due to pressure on the pelvic viscera, vesical and rectal tenes- 
mus, incontinence or retention of urine, constipation, hemorrhoids, and 
also pains in the legs and oedema from pressure on the pelvic nerves and 
vessels. All of these symptoms may disappear on the sudden escape 
of the tumor from the small pelvis into the abdominal cavity. The 
menstruations are often profuse and usually painless. There is often 
profuse leucorrhoea. Sterility is a frequent, but not inevitable result, so 
that pregnancy can occur even when both ovaries show cystic degenera- 
tion, and, if the cyst or cysts are small and not fixed in the pelvis by 
adhesions, the pregnancy can go to term without serious complications. 
When the tumor has reached a considerable size disturbances of the 
gastro-intestinal tract are common. Breast-changes similar to those of 
pregnancy may appear. The urinary secretion may be scanty from 
pressure of the tumor on the kidneys. The upward displacement of 
the diaphragm causes the ordinary symptoms of cardiac and pulmonary 
insufficiency. Adhesions between the tumor and the surrounding parts 
are often the cause of serious symptoms, such as intestinal colic, vomit- 
ing, etc. These symptoms may be altered by change in the position of 
the patient. Sooner or later malnutrition, anaemia, and cachexia appear. 
These patients often have a peculiar facial expression, the facies ovariana, 
but this must be seen to be recognized. 
In many cases there are absolutely no subjective symptoms, and the 
patient’s attention is first attracted by the increasing size of the 
abdomen. 
When complications arise, such as torsion of the pedicle, rupture of 
the cyst, or hemorrhage into the cyst, the symptoms are sudden and 
severe. Shock, acute anaemia, and the like are followed often by symp- 
toms of peritonitis. 
Examination of the patient should be preceded by free catharsis, aided by copi- 
ous eneinata, until one is certain that the colon is free from fecal masses. The 
bladder should be emptied with the catheter if there is any reason for suspecting 
that the voluntary evacuation is incomplete. If the resistance of the abdominal 
walls be too great or the pain too severe, the examination should be made under 
anaesthesia. The patient should be placed on the back with abdomen fully ex- 
posed. The size of the abdomen varies with the size of the tumor, but the enlarge- THE OVARY. 
555 
ment is usually asymmetrical, the side on which the tumor lies being the fuller. 
Percussion over the tumor gives dulness, but unless the tumor is closely adherent 
to the abdominal wall the area of absolute dulness is less than the size of the 
tumor as shown by palpation. If dulness is present in the flank, it is not altered 
with position of the patient, as it is in cases of ascites. Fluctuation of the cyst- 
contents is the plainer the more neai’ly the cyst is unilocular. Palpation of the 
tumor is done both through the abdominal wall and by bimanual manipulation. 
It should be done gently, for fear of rupturing the cyst or tearing some adhesions. 
No general rule can be given as to the position of the uterus, for it is dependent on 
a variety of factors—the size of the cyst, its point of origin, the presence or absence 
of adhesions. The uterus may be pulled up out of the pelvis or pushed down to 
the vulva. It may be forward or back or to one side. The length of the cavity is 
not usually increased, but it may be. 
The differential diagnosis of ovarian cysts is a very broad matter, so 
that there is no abdominal organ which does not under some circum- 
stances enter into consideration. Munde gives the following list of 
possibilities: Obesity, oedema, tonic spasm of the abdominal wall, tympa- 
nitis, fecal tumor, dilatation of the stomach, distended bladder, hcemato- 
metra, physometra, hydatiform mole, hydrosalpinx, ascites, encysted dropsy, 
hcematocele, cyst of the broad ligament, renal cyst, splenic cyst, hepatic cyst, 
parasitic cyst, omental and pancreatic cyst, uterine cysto-fibroma, uterine 
fibroma, enlarged spleen, enlarged liver, sarcoma of the abdominal nodes, 
malignant disease, omental tumor, displaced kidney, displaced liver, preg- 
nancy both normal and extra-uterine, pregnancy with amniotic dropsy, with 
ovarian cyst, and with a dead child. 
Even this formidable list might be extended. Fortunately, the means of 
differentiation in most of the cases readily suggest themselves. When the cyst is 
small the differentiation from other small tumors near the uterus may be difficult. 
A small focus of inflammation in the periuterine cellular tissue can usually be dis- 
tinguished by the history or presence of signs of inflammation. These tumors are 
less sharply circumscribed than the cysts. Extra-uterine pregnancy must be 
thought of when there is amenorrhoea, vulvar discoloration, and breast-changes. 
Retroflexion of a gravid uterus is suspected when the tumor is found in the cul- 
de-sac with the usually early signs of pregnancy. When the tumor rises out of the 
pelvis other questions arise. Differentiation from pregnancy, especially when an 
amenorrhoea exists, has caused confusion. The presence of any of the certain signs 
of pregnancy settles the question, but in some cases time or an exploratory lapa- 
rotomy may be necessary. When both pregnancy and a cyst exist the question is 
still more difficult. Ascites may resemble a large cyst, but with ascites the flanks 
are more distended, there is usually an area of tympany about the umbilicus when 
the patient is flat on her back, and the fluid moves freely with the changing position 
of the patient. Examination of other parts of the body will usually show the 
presence of some cause for the ascites. It must also be remembered that papillary 
cystoma not infrequently causes ascites. Localized tubercular or cancerous peri- 
tonitis is often difficult to recognize. The presence of tuberculosis in other parts 
of the body must suggest the possibility of a tubercular peritonitis. With carci- 
noma we may be able to palpate irregular nodules. Puncture of the abdomen 
may greatly facilitate palpation, but this procedure should always be done with 
great care, and it is not certain that a small exploratory incision is not a prefer- 
able plan. Microscopical and chemical examination of fluid removed may be of 
great assistance. Renal tumors, hydronephrosis, sometimes cause confusion. Here 
the history, the examination of the urine, the relation of the tumor to the colon 
after inflation of the colon with air, and the presence of a large amount of urea 
in the fluid of a hydronephrosis will usually render the correct diagnosis possible. 
When in any case careful and repeated examinations have failed to yield certain 
results, an exploratory incision should be made. 
The only treatment of ovarian cysts is removal. The patient is 
prepared as for other cceliotomies. The abdomen is opened in the median 556 
THE FEMALE REPRODUCTIVE ORGANS. 
line just above the pubes. Any adhesions are separated, the smaller 
torn with the fingers, the larger divided between ligatures. In some 
cases the adhesions are so abundant that the operation must be aban- 
doned. After freeing the cyst from adhesions the contents are drawn 
off' through a trocar, taking care that none of the fluid escapes into the 
abdominal cavity. The sac is now drawn out through the abdominal 
incision. The pedicle is tied with a heavy ligature, usually in two or 
nfore parts. The cyst is cut away, and after tying with separate liga- 
tures any large vessels found in the stump, the stump is dropped back 
into the abdomen and the incision closed. The after-treatment is the 
same as in other laparotomies. 
The Parametrium. 
Acute inflammatory processes in the para-uterine cellular tissue 
are most commonly the results of infection during labor or abortion. 
They may also follow operation on the genitalia or be due to extension 
from an infective inflammatory process existing in some of the pelvic 
organs—the tubes, ovaries, uterus, or rectum. 
There is serous and cellular infiltration of the cellular tissue, vary- 
ing in extent and location, but more often found in the broad ligaments, 
where it may remain or extend to all the uterine ligaments, the abdom- 
inal wall, the post-peritoneal and post-rectal cellular tissues. It may 
take the form of a diffuse phlegmon, as thrombo-phlebitis or thrombo- 
lymphangitis. The exudate may undergo complete resorption and the 
parts be restored to their normal condition, or the exudate may become 
purulent, forming an abscess. The abscess may be single or there 
may be many communicating with each other by tortuous passages. If 
untreated, the pus may undergo partial absorption, caseation, and cal- 
cification, but, as a rule, such abscesses increase in size and extend 
along lines determined by the fascial planes and the influence of gravity. 
They often rupture through the abdominal wall, the vagina, the rectum, 
or the bladder. They may also rupture into the peritoneal cavity. 
Another possible outcome of a cellular infiltration is its organization 
with the formation of new fibrous tissue. A similar formation of new 
tissue occurs about abscess-cavities unless the abscesses are promptly 
and thoroughly drained. 
Cases of parametritis are almost invariably associated with more or 
less extensive perimetritis. 
The symptoms are the general symptoms of all acute septic pro- 
cesses combined with the symptoms of the local trouble. Usually a 
chill, often very severe, is the first sign ; the pulse and respiration are 
rapid. The temperature is high and interrupted at varying intervals 
by chills. Pain from tension of the ligaments and abdominal walls and 
from pressure on the pelvic nerve-trunks, added to that of the usually 
accompanying pelvic peritonitis, is severe. Vesical tenesmus is often 
troublesome. Vomiting and tympany of the intestines are common. 
The general strength is rapidly undermined. The emaciation becomes 
extreme. The symptoms of rupture of an abscess into the general 
peritoneal cavity are those of a severe generalized peritonitis. In the 
more favorable cases the symptoms are less severe and of shorter dura- THE PERIMETRIUM. 
557 
tion. Vaginal examination shows local heat, swelling, and tenderness, 
with a generally boggy feeling. Later the swelling increases, causing 
displacement of the uterus. If pus form, fluctuation can usually be 
discovered. 
Treatment.—In the very early stages the patient should be kept 
in bed under the influence of opiates, with the local application of the 
ice-bag. The general health of the patient should be maintained by 
the use of alcoholics, quinine, and strychnia. If suppuration seems to 
be inevitable, cold should give place to hot applications and douches. 
As soon as a focus of pus can be discovered it should be opened and 
drained. It is usually best to locate the pus with an exploring syringe, 
and open along the needle with the thermo-cautery or sharp-pointed 
scissors, taking care to avoid any pulsating vessels and withdrawing the 
scissors open. The abscess-cavity should be explored to see whether it 
communicates with any other cavities. If it does, the opening between 
them should be enlarged sufficiently to secure free drainage. The 
abscess-cavity should be irrigated frequently with antiseptic solutions, 
and free drainage be maintained until the cavity closes throughout. If 
there is much new tissue formed after the abscess is closed, pelvic 
massage, combined with hot douches, iodine locally, should be used to 
limit the deformity resulting from the contractions of the new tissue, 
and as far as possible to cause the absorption of such tissue. 
The Perimetrium. 
Perimetritis, or pelvic peritonitis, is most often secondary to disease 
of the pelvic organs, though it occurs also as a part of a general peri- 
tonitis. The most common cause is infection following labor or abor- 
tion. Other causes are acute and chronic endometritis and metritis, 
gonorrhoea, inflammation of the tubes and ovaries, malposition and 
tumors of the ovaries, and exposure, especially during menstruation. 
The inflammation may lead to the formation of abundant fibrinous or purulent 
exudate, filling up the cul-de-sac of Douglas, and matting together the pelvic 
organs and such of the intestines as happen to lie in the pelvis. After a varying 
period of time the exudate may be absorbed; more frequently abscesses form which 
sooner or later perforate in some direction. These cases most frequently follow 
puerperal infection. Much more important, because much more frequent, are 
those cases in which the exudate is less abundant and fibrinous, and by its organ- 
ization leads to the formation of adhesions between any two peritoneal surfaces 
which happen to be in contact. These adhesions by the contractions which they 
undergo lead to the most diverse displacements and distortions of the pelvic 
organs, to circulatory disturbances by compression of arteries and veins, and to 
disturbance of the functions of the organs. The uterus is dislocated, atrophied 
when the blood-supply is cut off, or passively congested when the veins are com- 
pressed. The nutrition and function of the tubes and ovaries are altered. They 
are dislocated and become chronically congested and inflamed. The function 
of the bladder and the rectum suffers. 
The symptoms vary as greatly as do the symptoms of generalized 
peritonitis. Even most severe purulent pelvic peritonitis may exist 
some time without causing marked symptoms. The acute form usually 
begins with a more or less marked chill, followed by high temperature 
and frequent pulse, constipation, followed shortly by tympanitic disten- 
tion of the intestines, vomiting, and collapse. There are localized pains 558 
T1IE FEMALE REPRODUCTIVE ORGANS. 
and tenderness witli vesical irritation. In less acute cases the general 
symptoms are less marked, and the local symptoms, especially the pain, 
come to the foreground. The pain is severe, and is increased by motion, 
menstruation, and examination. The patients lose strength rapidly, 
suffer from insomnia, and often very much from vesical tenesmus. The 
chronic cases often develop without causing any subjective symptoms 
whatever, and the earlier existence of a pelvic inflammation is shown 
only by the resulting adhesions. The symptoms in these cases come on 
later from the disturbance of the uterus, bladder, and rectum—profuse 
menstruation, leucorrhcea, vesical tenesmus, constipation, pain in the 
back, sterility, or repeated abortions. 
Examination of the acute cases shows extreme tenderness over the abdomen, 
tympany, and tension of the abdominal walls. Vaginal examination shows the 
uterus fixed by the exudate about it, especially in the Douglas cul-de-sac. The 
vaginal fornices are bulging. Pulsating vessels are often felt. Examination of 
the cases which develop insidiously show some abdominal tenderness and consid- 
erable vaginal tenderness. The uterus is usually displaced backward and fixed. 
Bands of tissue irregularly arranged can often be felt. The severe cases coming 
on after labor or abortion may cause death rapidly or the exudate may soften and 
be discharged. Other possibilities are slow absorption or organization of the 
exudate. Complete recovery does occur, but it is exceptional. Even though the 
symptoms disappear for a time, they usually reappear upon the slightest provo- 
cation. 
The treatment of the acute cases consists in ice locally and rest in 
bed. The pain must be controlled by opium. The bowels must be 
kept open by laxatives. The strength should be maintained by alco- 
holics and tonics. After the more acute symptoms have disappeared 
hot local applications are used. If pus form, the abscess must be 
drained freely, as already described. The chronic cases should pass 
several hours in bed and the bowels be kept open. All repeated or pro- 
longed examinations, the use of the uterine sound or pessary, are contra- 
indicated, because of the danger of setting up an acute exacerbation of 
the chronic peritonitis. Hot or cold applications should be used for 
the pain. In some cases the extirpation of the tubes, ovaries, and the 
adhesions about them is warranted. 
The Fallopian Tubes. 
Inflammation of the Fallopian tubes may be acute or chronic. 
Although salpingitis was not recognized until a few years ago, the con- 
dition is far from being uncommon. The disease is rarely limited to 
the tubes. The uterus is diseased in about two-thirds of the cases, show- 
ing either acute or chronic endometritis, flexion, or version. Many 
cases show distinct traces of perimetritis, which, however, may be sec- 
ondary rather than primary to the salpingitis. It is probable that the 
tubes are rarely the seat of primary inflammation, except for the not 
infrequent cases of tubal tuberculosis. Many cases are due to puerperal 
infection. Many cases are due also to acute gonorrhoea. Both tubes 
are diseased in about half of the cases, and when only one tube is 
involved the left is involved more frequently than the right. 
The pathological process in the acute cases resembles acute catarrh of other 
mucous membranes. The membrane is swollen and red, with large or small 
eccliymoses under the epithelium, and, when the process is more intense, there is ECTOPIC PREGNANCY. 
559 
a round-celled infiltration, causing thickening of the mucous membrane. There 
is increased secretion, slimy and usually clear, but sometimes mixed with blood. 
The epithelium is retained. When the inflammation is more severe and due to 
the pus-cocci or the gonococci, the changes are more marked. The epithelium is 
exfoliated; the deeper portions of the mucous membrane and muscularis are 
dotted with ecchymotic areas and thickened by an extensive round-celled infiltra- 
tion. The muscle-fibres undergo fatty changes. Whenever two spots of the 
mucous membrane which has lost its epithelial covering come in contact, adhe- 
sions are liable to form, in this way dividing the cavity of the tube into irregular 
spaces, and in places, especially at the ends of the tubes, causing stenosis or atresia. 
The walls become thick and fibrous from organization of the exudate. The cavi- 
ties are often distended with pus, which after a time may become caseous from 
absorption of its fluid and fatty degeneration of its formed elements. The perito- 
neum is usually involved early, the cause of the inflammation reaching the peri- 
toneum either by extension through the walls of the tubes or by being carried by 
the secretions escaping through the abdominal end of the tube into the peritoneum. 
The peritoneum presents the changes common to inflammations of the serous 
membranes. The adhesions which form are often extensive. Their location is 
dependent upon chance. 
The symptoms of salpingitis are not well marked, because they are 
almost invariably added to a preceding or coincident inflammation of 
some other part of the genital tract. A dull pain of varying intensity on 
one or both sides, and increased by exertion, menstruation, or copula- 
tion, is usually the first sign. To this may be added at irregular inter- 
vals signs of acute localized peritonitis. The menstruations are irregu- 
lar, profuse, and painful. Occasionally the tube will empty itself into 
the uterus and a large amount of fluid escape into the vagina. At such 
times the pain is much relieved and the local findings are altered. 
The presence of pus in the tubes—i. e. pyosalpinx—causes the general 
symptoms common to all suppurating foci. When suddenly developed 
there is the chill and the irregular temperature curve, rapid pulse, and 
rapid loss of strength and flesh. Pus-tubes rarely rupture into the free 
peritoneal cavity. The usually firm adhesions prevent this. 
A positive diagnosis of salpingitis can be made only when the 
dilated tube can be differentiated by palpation from the exudate, and its 
connection to the uterus by the uterine end of the tube definitely deter- 
mined. Palpation, in these cases, must be most careful, because of the 
danger of rupturing the tube, causing severe local or general peritonitis, 
or tearing an adhesion and setting up a hemorrhage which may be so 
severe as to necessitate a laparotomy to find and control the bleeding 
point. 
Treatment for the acute cases is the same as for peri- and para- 
metritis. Later, hot douches, iodine preparations locally, rest, proper 
diet, and regulation of the bowels often accomplish a great deal toward 
the absorption of the exudate. If, after this plan have been faithfully 
tried, the symptoms persist, the tube or tubes should be removed. 
Ectopic Pregnancy. 
Extra-uterine pregnancy is the development of an ovum outside of 
the normal uterine cavity. Formerly this was thought to be a rare 
occurrence, but increasing experience shows that it is far from being so. 
Anatomically, the cases are classified according to the site of the devel- 
opment of the foetus into tubal, tubo-uterine or interstitial, tubo-abdom- 560 
THE FEMALE REPRODUCTIVE ORGANS. 
inal, abdominal, subperitoneal, and others. This classification is of but 
little clinical value. 
It is known that impregnation of the ovum often occurs near the 
ovary. Any cause which will prevent the passage of the impregnated 
ovum to the uterus may cause an extra-uterine pregnancy. The more 
common of these causes are inflammation of the Fallopian tubes, pelvic 
peritonitis about the tubes leading to constriction, tumor, or polypi in 
the tube. 
Tubal pregnancy is the most common form, and may occur at any 
part of the tube, but most often in the middle third. The tubal mucous 
membrane undergoes changes similar to those of the uterine membrane 
in the formation of the decidua. During the earlier months of preg- 
nancy the tumor resembles a hsematosalpinx, and can be distinguished 
only by finding foetal parts or remains of chorionic villi. Rupture of 
the tube occurs early in the majority of cases. It ruptures most fre- 
quently into the peritoneal cavity, causing an intraperitoneal hsematocele 
which may be so large as to exsanguinate the patient. Rupture between 
the folds of the broad ligaments is more favorable, as the ligaments tend 
to limit the hemorrhage. Sometimes the foetus dies early and the tumor 
stops enlarging. In these cases, after a feAV months, it may be difficult 
to recognize the true nature of the tumor, the foetus having entirely dis- 
appeared. In other cases the foetus may live to term, developing in the 
fold of the broad ligament, making the so-called subperitoneal extra- 
uterine pregnancy, or free in the abdominal cavity as a secondary 
abdominal pregnancy. 
In the tubo-uterine or interstitial form the foetus develops in that 
part of the tube which lies in the uterine Avail. The pregnancy usually 
continues longer than in the tubal form. It may rupture into the uterine 
cavity, with escape of foetus and placenta through the natural passage, 
or it may rupture into the peritoneal cavity. Sometimes the pregnancy 
goes to term. 
In the tubo-abdominal cases the OATum develops in the abdominal 
end of the tube. The sac is made up in part by the tube and in part by 
false membrane. The sac is adherent to those organs with which it 
comes in contact. The placenta is usually located in the peh’is. It may 
go on to term, but as a rule ruptures. 
Abdominal pregnancy may be primary—i. e. the ovum is impreg- 
nated and remains in the abdominal cavity—but it is usually secondary 
to rupture of some other of the forms. The sac is usually made up of 
thick false membranes, but it may be thin and transparent. The pla- 
centa is large and irregular both in site and shape. When the ovum is 
not strangulated, it usually develops to term, uninterrupted by hemor- 
rhage or rupture. 
The uterus is, as a rule, enlarged, and its mucous membrane sIioavs 
changes similar to those which occur with intra-uterine pregnancy. Its 
location varies Avith the site of the ovum, but it is more often displaced 
forward or to the side opposite the ovum. 
The patient presents all or many of the early signs of pregnancy, 
but usually there is some irregularity in the course to attract attention. 
The of the breasts may not occur, or the menstruation, 
after disappearing, reappears, often as a continuous Aoav. There may be ECTOPIC PREGNANCY. 
561 
expulsion of decidual membranes without any change in the signs of 
pregnancy. 
When rupture occurs the symptoms are those of internal hemor- 
rhage, varying in intensity with the amount of blood lost. If pregnancy 
goes on to term, we find symptoms due to compression of the rectum and 
bladder, intestinal colic, and recurring peritonitis. If infection of a 
hsematocele or retained ovum occur, we have the symptoms of septicaemia 
and peritonitis, either generalized or local. If the suppuration is local- 
ized, it ends as other pelvic abscesses end. It also happens that after 
the death of the foetus no symptoms result, the foetus being retained as 
a non-infected foreign body. It may undergo calcification, forming a 
lithopaedion. In such cases the condition may persist for many years 
without causing any trouble, but it is a constant source of danger, as 
it may at any time cause serious complications, such as intestinal ob- 
structions. 
The diagnosis of extra-uterine pregnancy previous to the fifth month 
cannot absolutely be made certain, because of the lack of positive signs 
of pregnancy previous to that time, but it must be suspected when sev- 
eral of the early signs of pregnancy are present, combined with irregular 
uterine hemorrhages, a disproportion between the period of the suspected 
pregnancy and the size of the uterus, and the presence in the pelvis of a 
tumor in close relation to the uterus. Commencing with the fifth month, 
we find positive signs of pregnancy combined with uterine hemorrhage, 
an irregularly-shaped tumor situated laterally, and a uterus not mate- 
rially enlarged. Diagnosis of the variety of extra-uterine pregnancy is 
impossible. False labor is shown by expulsive pains, usually at term. 
Death of the foetus is shown by the loss of the foetal heart-tone with 
decrease in the size of the tumor, with softening. 
It must be remembered in treating these cases that the danger of 
hemorrhage and sepsis is so great, and the chances of the spontaneous 
expulsion of the foetus or the safe retention of a dead foetus are so small, 
that to-day the only rational treatment of extra-uterine pregnancy 
is operation. The earlier treatments, such as starvation, bleeding, 
puncture of the cyst, strychnia to toxic symptoms, are abandoned. The 
use of morphine injections into the tumor previous to the fifth month is 
still sometimes practised with success, but it is more dangerous than 
laparotomy. The same thing can be said of the use of electricity. If 
before the fifth month extra-uterine pregnancy be suspected with any 
degree of probability, exploratory laparotomy should be performed, and, 
if the diagnosis be confirmed, the cyst and its contents should be removed. 
Whenever rupture of the sac occurs a cceliotomy should he made at 
once, without waiting for signs of serious hemorrhage. After the fifth 
month, if the foetus be living, operation should be deferred until term or 
until signs of false labor appear, unless some indication for immediate 
operation develops. After the fifth month with a dead foetus the opera- 
tion should be made as soon as possible, even though the foetus lias been 
retained for years without causing any trouble. 
Operations for extra-uterine pregnancy are of two classes—laparot- 
omy and elytrotomy—i. e. operation per vaginam. The special features 
of each case must decide which of these operations shall be performed. 
Hemorrhage, which is the greatest danger of the operation, is best con- 562 
THE FEMALE REPRODUCTIVE ORGANS. 
trolled by the iodoform-gauze tampon. Whenever possible the entire sac 
and its contents should be removed. When the sac cannot be removed 
because of adhesions or for some other reason, it should be stitched to 
the abdominal incision, then opened and its contents removed, and then 
packed with iodoform gauze and allowed to close from the bottom. 
When operation through the vagina is done, the vault of the vagina 
is incised at a point near the tumor, and the opening enlarged sufficiently 
to allow the extraction of the foetus. The cord is tied and the placenta 
removed when possible. When impossible, the cavity is irrigated and 
packed with iodoform gauze. CHAPTER X IY. 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
Charles B. Parker, M. D. 
The Development of the Breast. 
The mammary glands appear in the human embryo in the second month as a 
considerable thickening of the epidermis in the position of the breasts; in the third 
month the proliferated epidermal cells of the rete mucosa form a slight depression 
in the true skin which is called the glandular area. Out of the wall of this area 
the gland-ducts and acini are formed by a further invagination of the skin by the 
epidermal cells; by the seventh month this process is well under way, and at birth 
the normal number of secreting lobules has been formed. At birth the nipple 
appears on a level with the skin. Gradually, in the first years the nipple rises as 
a prominence by the thickening of the epithelium about the gland-ducts and the 
development of a considerable quantity of involuntary muscular fibre, together 
with blood-vessels, nerves, and lymphatics. The manner of development of the 
milk-glands is after that of the sweat rather than of the sebaceous glands. Accord- 
ing to Heidenhain, the secretion of milk also takes place after the manner of the 
formation of sweat, directly from the wall of the secreting structure, and not by a 
metamorphosis of the central cells as in the formation of sebum. The mammary 
glands are developed in exactly the same manner in the male and the female, and they 
remain identical until nearly the period of puberty. From this time onward the 
development is very rapid in the female, while in the male it does not extend 
beyond the nipple and areola. The male breast thus, from its origin and develop- 
ment, is equally liable to, though much less frequently the seat of, disease and 
tumor-formation. 
Anatomy of the Breast.—The following data in the topographical anatomy 
of the female breast have an important bearing upon the surgical treatment of its 
injuries and diseases. Morris and others describe the mammary gland as extend- 
ing from the third to the seventh rib from above downward, and from the sternum 
(which it slightly overlaps) to the axillary border from within outward. Astley 
Cooper gives its vertical extent from the third to the sixth rib, and Treves places 
it as covering the space from the third to the fifth rib. These observations serve 
to show that there may be considerable variation in the vertical extent of the gland. 
The breast is also not circular in outline, but presents three cusps—one overlap- 
ping the sternum, and the others toward the axilla, the one above, the other below. 
Heidenhain describes lesser extensions of the gland passing to the deep fascia, 
and even penetrating it in some cases. These portions of the gland have often been 
left behind after operation for malignant growth, and have become the source of a 
recurrence. 
Each gland is composed of a connective-tissue framework enclosing secreting 
elements, blood-vessels, nerves, and lymphatics. The connective tissue from its 
firm attachment to the sternum and intercostal spaces spreads out into an outer and 
inner layer, between which the gland is supported: the outer layer does not form a 
true capsule, as it is reflected in with the ducts, and forms, together with similar sub- 
divisions of the inner connective-tissue layer, the fibrous septa between the lobules 
of the gland, while more superficial subdivisions spread out and become incorpo- 
rated with the under surface of the skin, forming the ligamenta suspensorda of Ast- 
ley Cooper. The inner layer passes behind the costal margin of the gland sending 
fascicular fibres inward between the lobules, and others outward to unite with the 
fascia of the pectoral muscle. The glandular tissue is composed of from twenty 
to thirty lobules, each including numerous acini and ducts opening within a cen- 564 
tral elevation, the nipple. The nipple is placed slightly internal to the middle of 
the breast over the fourth intercostal space. The direction of the nipple is out- 
ward and forward. The nipple is supplied with a rich anastomosing plexus of 
blood-vessels and erectile tissue. 
The areola, the pigmented skin about the nipple, is very thin—contains a num- 
ber of stubborn hairs and prominent sebaceous glands. During the later period of 
pregnancy larger glands appear in the areola, from which, according to Mont- 
gomery, milk can be pressed. Duval showed that they have no connection with 
the true milk-secreting portions of the breast. Luschka described them under the 
name of glandulce lactiferce aberrantes. The blood-vessels are derived from three 
sources: tirst, numerous important arteries given off from perforating branches of 
the internal mammary in the third, fourth, and fifth intercostal spaces, and dis- 
tributed to the body, sternal, and costal sides of the gland; second, large branches 
from the external mammary, and long thoracic arteries passing to the body and 
axillary sides; and third, numerous though smaller branches from the thoracico- 
acromial artery to the superior border of the gland. 
The lymphatics are very numerous, and form both superficial and deep plexuses 
within the gland. The lymph-stream flows from the gland in three directions— 
outward, to the axilla; inward, toward the sternum; and directly backward, to the 
muscular fascia. The principal stream gathered from the body and outer border 
of the gland jiasses in the lymphatic vessels along the lower border of the pectoralis 
major, pierces the fascia forming the floor of the axilla, and, after entering numer- 
ous lymphatic nodes, forms a trunk on the inner side of the axillary vessels. 
Opposite the first rib it penetrates the costo-clavicular ligament and terminates at 
the junction of the internal jugular and subclavian veins, on the right side uniting 
with the right lymphatic from the upper extremity, and on the left with the tho- 
racic duct. Another set of vessels, gathering the lymph from the nipple and 
superficial portions of the gland, pass behind the axillary vessels and enter the 
absorbent trunk of the arm; from the sternal side the lymphatics follow the veins 
of the perforating branches of the internal mammary artery, and enter the lym- 
phatic nodes of the anterior mediastinum; numerous lymphatics from the costal 
surface of the breast pierce the muscular fascia and intercostal spaces to join the 
lymphatics which accompany the aortic intercostal arteries. Volkmann, from his 
clinical observation, insisted that the communication between the lymphatic sys- 
tems of the fascia and breast was not free—that the lymphatics of the muscular 
fascia formed, in fact, a temporary barrier to the lymph-stream from the breast, 
and thus to infection of the system in this direction. Ludwick demonstrated that 
the physiological lvmph-current is from muscle to fascia. Heidenliain also proved 
the correctness of Volkmann’s clinical observation, and further found that when 
the lymphatic vessels are once charged with infective elements these pass at once 
through the lymphatics of the intervening fat. The fat, therefore, separating the 
gland from the chest-wall, is no protection whatever against the transmission of 
infective elements. From the source and direction of tbe various lymph-streams 
it will be seen that cancerous tumors located in the outer portions of the breast 
and about the nipple would first produce secondary deposits in the axillary and 
clavicular lymphatics; when located on the sternal and posterior portions of the 
mammary glands the first metastatic deposits might occur in the mediastinal and 
intrathoracic lymphatics rather than in those of the axilla. 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
Anomalies op the Breast. 
Complete absence of one breast (Amazon thorax, Hyrtl) or of 
both breasts is most rare. In those cases in which the breast lias been 
absent the condition was observed to be associated with marked devel- 
opmental defects in other organs, such as the uterus, ovaries, pectoral 
muscles, and ribs. Supernumerary breasts (polymastia) or multiple 
nipples (polythelia) are not so uncommon. 
The mother of the Roman emperor, Alexander Severus, bore the name of Julia 
Mammea, from the fact that she possessed a third breast. The discovery by King 
Henry of a supernumerary breast on the person of the beautiful Anne Boleyn is 
said to have been the cause of her downfall and death. DISEASES OF THE NIPPLE AND AREOLA. 
565 
The supernumerary breasts are usually located internally to, and 
below, the principal gland. The axillary border, and even Scarpa’s 
space, have been the seat of functionating mammary glands. There seems 
to be no relation between these anomalies and diseases of the breast. 
Billroth says that in all his experience he has seen but one case—a car- 
cinoma—occurring in a breast with two nipples. This observation is 
not altogether confirmed by other authorities, but we may safely say it 
is never necessary to remove these supernumerary organs simply because 
they are present. 
Skin Diseases occurring on the Breast. 
The skin and areola of the breast are liable to the various skin 
affections, especially eczema, which frequently occurs upon the nipple 
and areola. Eczema in this position, as well as other skin affections 
when they occur, do not differ in any essential character or in treat- 
ment from the same disease occurring on other parts of the skin. A 
peculiar affection of the nipple and areola very closely resembling 
eczema, and known as Paget’s disease of the nipple, is occasionally 
met with. This disease receives its greatest importance from the fact 
that it is frequently followed by carcinoma in the breast. (For a 
detailed account of this subject see Chapter XXA’T. Vol. I. (Carcinoma). 
Wounds and Burns ; Hemorrhage ; Vicarious Menstruation. 
The toughness of the skin on the breasts, and their mobility, are such 
that it requires a tremendous force to injure them, and in such cases 
the injury to the chest and its contents is far more important. Punc- 
tured wounds are occasionally met with; more frequently, however, the 
breast is wounded by kicks and blows. Such injuries and their treat- 
ment require no extended notice. They are chiefly noteworthy as form- 
ing the possible origin of subsequent tumor-formation within the breast. 
Hemorrhages have been occasionally observed occurring in the 
breasts of young women and girls suffering from dysmenorrhoea, amen- 
orrhoea, and other uterine disorders where there has been no external 
injury. Such an extravasation of blood is called vicarious menstruation. 
The extruded blood produces no pain and, at most, only a sense of ful- 
ness in the breasts. 
The TREATMENT consists in supporting the breasts with a handker- 
chief bandage tied over the opposite shoulder and the application of 
dilute lead lotion. 
Inflammation is especially liable to occur during the early days of 
the first lactation, and in subjects in whom the nipple is ill developed. 
The nipple receives a slight injury while the child is at the breast. The 
moisture incident to the act of nursing macerates and loosens the injured 
epidermis, which, separating, leaves a superficial excoriation. This 
deepens into a fissure and may extend to a considerable ulcer. The pain 
increases with every attempt made to place the child at the breast. The 
Diseases of the Nipple and Areola.  SURGICAL DISEASES AND INJURIES OF THE BREAST. 
566 
dread of this pain leads the mother to extend the intervals of nursing, 
and the breast becomes distended with milk ; but the real danger in these 
fissures and ulcers lies in the fact that through them an avenue is opened 
for the introduction of bacteria, especially the streptococci and staphy- 
lococci. The result is inflammation of the substance of the gland. 
The prevention and treatment of this condition become of the first 
importance. 
During pregnancy the nipples may be hardened by frequent bathing in alcohol 
and water; and should they be imperfectly developed systematic efforts are to be 
made to draw them out. When the child begins to nurse the greatest care must 
be exercised to keep the nipples clean and dry. Immediately upon the child being 
taken from the breast the nipple and areola are to be washed in sterilized water 
and thoroughly dried ; upon the appearance of the slightest abrasion they must be 
kept perfectly clean by frequent bathing in boiled water and subsequent careful 
drying of the surface. A nipple-shield must be used when the child is again put 
to the breast. 
Should a fissure of the nipple form as a result of this abrasion, it 
should be treated upon antiseptic principles. The greatest care is to be 
exercised in cleansing the nipple and fissure with boiled water after 
nursing, and the application of moist antiseptic dressings. Boracic-acid 
solution, gr. x to |j, or creolin, or even bichloride, 1 : 6000 or 10,000, 
may be applied to the breast during the intervals of nursing. Some 
impervious covering, such as oil silk or paraffin paper, should be applied 
over the moist dressing. All ointments should be avoided : not only 
are they of doubtful utility, but they chiefly serve as an impervious 
coating over the fissure, keeping in the secretions and bacteria and favor- 
ing their absorption. When the child is about to be put to the breast 
again, the dressings are removed and the surface thoroughly washed with 
sterilized water and dried. If the fissure persists and shows no tendency 
to heal, touching it with a sharp stick of silver nitrate will often start 
the healing process. Should these means fail after a reasonable trial, 
and the patient’s health begin to suffer from the pain, and possibly both 
breasts become similarly affected, with the danger of infection from pyo- 
genic microbes thus doubled, it is the evident duty of the physician to 
arrest the secretion of milk at once and in both breasts, whether they 
are both diseased or not. It is not sufficient to arrest secretion in the 
affected breast alone : the sympathetic relationship between the two is so 
intimate that nursing on a healthy mamma stimulates the diseased breast 
to renewed secretion. Such half measures have often protracted this 
painful affection for many weeks. The local application of belladonna 
ointment and the administration of potassium iodide in full doses have 
the approval of accepted practice; but the equable continuous pressure 
secured by strapping both breasts is far more effective and affords more 
prompt and permanent relief. 
Strapping the Breasts.—The patient is seated in a chair, the cloth- 
ing removed from the bust, and the skin rendered aseptic by the use of 
soap and water, bichloride solution, 1 :1000, alcohol, and finally ether. 
By taking this precaution the straps may be worn for a much longer 
time without producing irritation of the skin. From four to six strips 
of adhesive plaster, two inches wide and of sufficient length to extend 
from the opposite shoulder under the breast and back to the shoulder, 
are to be cut, and just as many more strips half this length. The ACUTE MASTITIS. 
567 
patient elevates the breast with the hand of the same side, while the 
surgeon carries the end of the plaster from the middle of the spine over 
the opposite shoulder obliquely downward under the breast and over the 
back to the point of starting. A second long strip is applied in the same 
manner, overlapping the previous one about one-third. A short circu- 
lar strip is next applied, passing from the sternum over the breast back 
to the spine. The subsequent straps are then applied alternately until 
the surface of the breast is entirely covered, and firm compression is 
thus made upon it. The nipple and areola must be protected by a 
small, dry antiseptic dressing. The opposite breast is treated in the 
same manner. A circular cloth bandage is not necessary. 
Acute Mastitis. 
Acute inflammation of the breast may occur—first, at birth; second, 
at puberty; third, during pregnancy and lactation. At Birth.—Not 
infrequently the breasts of the new-born infant of both sexes secrete a 
milk-like fluid (“ witch’s milk ”) for several days. The breasts are 
turgid, red, and tender. The practice of the untrained nurse of “ rub- 
bing away ” the milk only aggravates the condition and leads to sup- 
puration and abscess-formation. With intelligent, trained care suppura- 
tion will be rare, and for the inflammation that may occur it will be 
necessary, at most, to apply a compress wet with dilute lead lotion, and 
the process entirely subsides in from a week to ten days. At puberty 
a similar turgescence and inflammation of the breasts may occur. It is 
less liable to proceed to suppuration, and requires no treatment beyond 
careful protection of the parts. 
During pregnancy and lactation acute inflammation is particularly 
liable to occur. Of 56 cases observed by Billroth, 50 occurred during 
this period—6 in non-pregnant women. Statistics seem further to 
prove that puerperal mastitis is more frequent upon the right than the 
left side, and rarely bilateral; also, that usually only a portion of the 
gland is affected, and that the lower external part. 
Distention of the milk-ducts does occur in puerperal mastitis, but cannot be 
assigned as the exciting cause of the inflammation. Roser long since pointed out 
that even greater distentions of the milk-ducts occur in women in whom nursing 
is suddenly interrupted, without leading to inflammation, and that the deten- 
tion of the milk in the inflamed duct is the result, and not the cause, of the in- 
flammation. 
Billroth insisted that there must be a special irritation to produce the 
process of inflammation ; and we now know that it is the infection of 
the breasts by bacteria that induces the inflammation. There are 
apparently two avenues by which the microbes enter—the one through 
the fissures and ulcers, however small, upon the nipple; the other 
through the milk-ducts by organisms which find their way in through 
the ducts or have their normal habitat in the deeper layers of the skin 
(Welch). Infected wounds in the genital passages may also produce 
metastases in the mammary glands. In most cases the inflammation 
remains limited to the points of original infection. The inflammatory 
process may reach a certain degree of intensity and then gradually sub- 
side, but more commonly it increases in severity and ends in suppura- 568 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
tion and abscess-formation. Such an abscess is known as an antero-, 
intra-, retro-mammary abscess according as it is located upon the gland, 
within the gland, or behind it. 
The symptoms of the inflammation leading up to the abscess are 
pronounced. With a history of Assured nipple in a primipara we have 
the sudden onset of pain—perhaps a chill, with increased tenderness in 
one portion of tiie breast. The redness of the skin which occurs early 
in the superficial abscess appears very late in the abscess located within 
the gland ; and in those placed behind it there may be no redpess of the 
skin over the breast at any time. Fluctuation also is very apparent 
in the superficial abscess ; it is often uncertain in the smaller deep- 
seated abscesses within the breast, and in those located behind it fluctua- 
tion may not be made out at all, and then only at the margin of the 
gland and when the abscess has already reached some size. 
The superficial mammary abscess is located usually near the 
nipple. Fluctuation occurs early ; the pus is just beneath the skin, 
which is red and already thinned by inflammatory softening. The 
abscess should be opened by an incision radiating from the nipple, to 
inflict the least possible damage to the secreting structure of the breast. 
The skin should be rendered aseptic, as lias been elsewhere described, 
and the incision so placed as to afford the best possible drainage; at the 
same time it should be through the thinnest part of the inflamed sur- 
face, where the abscess would probably break if left to itself. If this 
last precaution be not taken, it is more than probable that an independent 
secondary opening will occur at this point. 
Intramammary abscess is a much more serious condition, and may, 
in severe cases, lead to a total destruction of the function of the gland 
by the formation of numerous multiple abscesses and their attendant 
sinuses. The fluctuation is not always easily made out, the elastic 
pillowy feel of the breast itself adding to the difficulty of the examina- 
tion. The signs of inflammation are the temperature, local tenderness, 
and the hardness which has existed for some days. Within a day or 
two softening of the area of hardness will be noticed, and within the 
next two or three days redness of the skin. 
Many writers, following the dictum of Velpeau, advise against incision into 
the breast itself to open these abscesses. The claim is made that if left to open 
itself the abscess will do so by making its way to the surface between the lobules 
and ducts without destroying them, as would necessarily be the case, to some 
extent at least, by incision. The danger of further local and general infection, 
however, far outweighs any such consideration, and the incision radiating from 
the nipple will inflict the least possible damage to the secreting tissues. In those 
cases where multiple abscesses have formed throughout the gland, with burrowing 
sinuses from one to another and to the surface, it may become necessary to ampu- 
tate the entire gland to arrest the process of suppuration. Such extreme measures 
ought rarely to be necessary when the early treatment of the affection has been 
properly carried out. 
Retro- or submammary abscess is fortunately rare. It may result 
from an extension of an intramammary suppuration or it may occur by 
metastasis. The onset may be most insidious, or it may be severe, with 
marked evidence of general septic infection. The gland itself may be 
only slightly involved, and is protruded outward, resting upon a cushion 
of pus. Usually the pus presents itself on the lower border of the gland 569 
CHRONIC MASTITIS. 
in a direction determined by gravity. It may, however, point along 
the upper border of the gland or in the axilla, and has been known to 
make extensive dissections of the chest-wall, and even to break into the 
thorax. As soon as discovered an opening along the lower or axillary 
border of the gland should be made to secure the very best possible 
drainage. After opening any of these varieties of abscess no pressure 
should be made upon their walls to force out their contents, nor should 
they be irrigated with any watery sterilized solutions. The flow of pus 
may be favored by the position of the patient, and the cavity should be 
gently, and not too tightly, packed with iodoform gauze and a volumin- 
ous antiseptic dressing applied. This dressing usually requires renewal 
upon the third or the fifth day, or sooner if the temperature rises to 
103° F. During all this time the breast must be efficiently supported, 
and no bandage equals in efficiency adhesive straps applied in the manner 
already described. The circular strips may be omitted in these cases, 
and only the long straps passing under the breast need be applied. 
Chronic Mastitis. 
The chronic lobar induration of some authors is a chronic inflam- 
matory process involving one or more lobules and ducts of one or both 
breasts. The cellular infiltration between the acini and the lobules 
becomes organized into dense connective tissue. This contracts, destroy- 
ing the acini or closing them off into retention-cysts containing a small 
quantity of brownish or colorless fluid. The lobule becomes nodular, 
irregular, and adherent to the structures adjacent. If the larger ducts 
are involved, retraction of the nipple may also occur. This form of 
chronic inflammation occurs in women who have not borne children as 
well as in those who have. Quite frequently it occurs in both breasts, 
and to some slight degree is present in women between the ages of forty 
and fifty. The pain is often severe and of a neuralgic character, and 
is frequently the first symptom that attracts the patient’s attention to 
the breast. The fear of malignant disease and the frequent handling 
exaggerate the pain and suffering. The differentiation from carcinoma 
is often most difficult. The two conditions occur at the same age—they 
each form irregular hard nodules, and the nipple may be retracted in 
each condition. The following points are of service in making out the 
differential diagnosis between— 
Chronic Induration. 
Leathery hard. 
Increased size during menstruation. 
Both breasts frequently affected. 
Growth very slow. 
Lymphatics usually not enlarged. 
No cachexia. 
Improves or remains stationary. 
Carcinoma. 
Stony hard. 
Size usually not affected by menstruation. 
Confined to one breast. 
Growth rapid. 
Lymphatics always enlarged (late). 
Always cachexia (late). 
Grows worse. 
Finally, the examination with the flat of the hand should he made: the 
clothing should be removed so that the breasts are entirely accessible. 
Before any examination is made with the fingers the palmar surface of 
the hand is placed flat upon the breast over the suspected spot, and with 
gentle pressure the lobules rolled over each other. If it be merely 570 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
chronic induration, nothing can be felt; if a tumor be present, it comes 
out more distinctly. If the patient is very thin, it is possible to mis- 
take a costal cartilage or an unusually curved rib for a new growth. 
This valuable aid to diagnosis does not serve to distinguish the various 
forms of new growth, but only to differentiate them from cases of 
chronic lobar inflammation. And it must be admitted that in the very 
beginnings of malignant disease, especially carcinoma, this method may 
fail. In any case of doubt, where all means of diagnosis fail, it is the 
duty of the surgeon to insist upon an exploratory incision, the inspection 
of the mass, and a microscopic examination of a specimen removed. 
The treatment of this condition by the administration of potassium 
iodide in full doses or by liquor potassse and arsenic is highly recom- 
mended. The most useful local treatment is strapping with adhesive 
straps, as has been elsewhere described. This procedure makes equable 
pressure over the entire breast, and thus favors the absorption of the 
new-formed connective tissue; at the same time the patient is prevented 
from handling the breasts and thus further aggravating the condition. 
Tuberculosis. 
In common with the other organs of the human body, the mammary glands do 
not enjoy immunity against the ravages of the bacillus of tuberculosis. They are, 
however, not so commonly affected with tuberculosis as would seem probable on 
account of their exposed situation and their intimate vascular relations with the 
body proper. No doubt tuberculosis of the breast is more common than seems at 
first apparent, for many cases of so-called chronic mastitis, chronic mammary abscess, 
and mammary fistula are the results of tubercular disease, and certainly the affec- 
tions described as scrofulous tumor and as cold abscess belong to this category. As 
a secondary disease tuberculosis of the breast may follow upon a tubercular 
empyema or ostitis of the ribs, in which infection by contiguity of structures 
occurs. The chronic mammary fistula, of certain authors is usually the result of a 
secondary tubercular disease in the breast consequent upon a primary infection 
of the adjacent pleural sac or ribs. Metastatic mammary tuberculosis, in which 
the infectious material obtains access to the breast through the vascular channels 
from a tubercular focus situated in some distant portion of the body is a possi- 
bility, though it is surprising when we think how rarely disease of the breast 
occurs, even in extensive or general tubercular disease of other organs. In pri- 
mary tuberculosis of the breast the tubercle bacillus must find its way into the 
organ through the same natural route chosen by other infective micro-organisms 
—that is, through the milk-ducts. Primary infection may also be possible through 
the avenue of an open wound upon the breast or nipple. 
Tuberculosis pursues the same course in the breast that marks its 
progress in other soft structures of the body (Vol. I. p. 174). 
The histological lesions are identical with those characterizing this 
form of granuloma, and the gross lesions deviate in no way from the 
usual types. Miliary tuberculosis can scarcely be defined from actual 
observation, for when encountered clinically the tubercles have usually 
passed into more or less caseous masses, which may be spread diffusely 
throughout the glands or become confluent as one or several large cir- 
cumscribed nodes. The nodules of diffuse tuberculosis vary in size and 
number. They are usually accompanied by a low grade of inflamma- 
tory action in the tissues surrounding them, so that the portion of the 
organ affected by the disease becomes both nodular and indurated. 
Cheesy degeneration of the tubercular nodules occurs in due time. 
Sooner or later the retrograde changes in the tubercular lesion lead TUBERCULOSIS. 
571 
to liquefaction of the caseous contents of the nodules, and the softened 
material thus formed burrows throughout the gland and eventually finds 
its way to the surface. In this way a series of discharging sinuses may 
be produced which riddle the breast in various directions. This fate is 
shared alike by the diffused and circumscribed tubercular lesions. 
Spontaneous healing has been noted in mammary tuberculosis in which 
the foci were small in number and of moderate size. Encapsulation by 
a protective connective-tissue barrier and absorption or calcification of 
the inner tubercular material affect the healing process. This method 
of termination is the exception, and the tubercular breast becomes an 
ever-present source of danger of general tubercular infection. Of the 
surrounding structures, the contiguous lymphatic nodes are usually 
infected from tuberculosis of the breast. Tuberculosis, like most other 
diseases of the mammae, attacks the gland by preference during the 
period of functional activity, and it thus happens that puberty, preg- 
nancy, and the puerperium are the occasions most commonly chosen. 
Diagnosis.—While by no means a common affection, the possibility 
of tuberculosis of the breast must not be lost sight of by the surgeon, 
and obscure chronic inflammatory or suppurative conditions, or circum- 
scribed and multiple nodes lacking the features of ordinary tumors, espe- 
cially if accompanied by anaemia, emaciation, and a typical fever, should 
arouse suspicions of the disease. Before the foci have softened a diag- 
nosis is often extremely difficult, especially in the case of the larger 
single tubercular masses, in which the involvement of the axillary lym- 
phatics strongly suggests cancer. After softening of the lesions has 
occurred, and particularly after an external opening and multiple inter- 
nal sinuses have established themselves, the diagnosis of tuberculosis 
becomes a much easier matter. 
From the ordinary pyogenic infections tuberculosis can usually be differenti- 
ated by the history of a sudden onset and the acute inflammatory symptoms of the 
disease, together with a microscopical and bacteriological examination of the exu- 
date, in which the pus-cells and the pyogenic cocci of acute infections will usually 
be found. Syphilitic gummata in the breast may very easily be mistaken for a cir- 
cumscribed tuberculosis, but here the specific history or the negative results of 
thorough antisyphilitic treatment will clear the doubt. 
The differentiation of tubercular disease from the ordinary tumors of the 
breast is usually readily accomplished when the various characteristics of mam- 
mary neoplasms are brought to mind. In all cases of doubt, however, a positive 
diagnosis of tuberculosis can be made by the microscopical or bacteriological 
methods or by both combined. A microscopic examination of the fluid exudate 
obtained from the discharging sinuses or by exploratory puncture will reveal the 
granular debris and lack of formed elements distinctive of tubercular pus. Prep- 
arations of the exudate stained by the ordinary methods for the tubercular bacilli 
may reveal these organisms. Finally, the inoculation of a susceptible animal, 
preferably a guinea-pig, with the suspected fluid will usually reveal the presence 
of the tubercle bacillus by reproducing the disease in the animal, even though 
all other methods of examination are negative. Even in those cases of mixed 
infection or secondary infection in which a pyogenic and tubercular infection occur 
together, and in which no suspicion of tubercular trouble would be obtained by 
the usual microscopical or bacteriological examinations, the inoculation test would 
still be available. In cases in which the suspected masses were still solid a piece 
of tissue could be removed with aseptic precautions and employed for inoculation 
experiments and for histological study. 
Treatment.—Thus far, we have no specific treatment for tubercu- 
losis, and this disease resists all of our therapeutic measures in much 572 
SURGICAL DISEASES AND INJURIES OF TIIE BREAST. 
the same way as cancer does. A focus of tubercular disease, like a 
tuberculous breast, constantly threatens the life of its possessor, since 
secondary disease in remote parts may spring from it at any time : there 
seems, therefore, to be but one rational method of treatment at present 
indicated in all accessible tubercular foci—viz. complete removal of the 
diseased tissues. In the breast this means the amputation of the dis- 
eased organ and the removal of infected lymph-nodes and other dis- 
eased tissue by substantially the same method as will be recommended 
for the removal of a carcinomatous breast. 
Syphilis is not necessarily a venereal disease. The breasts, next to 
the lips and mouth, are perhaps most frequently the seat of the initial 
lesion in non-venereal chancre. In one mode of infection the virus is 
carried from the syphilitic infant through fissures and abrasions of 
the nipple to the mother or wet-nurse. ATarious unique and unusual 
sources are given in the literature. The chancre, however acquired, 
takes on the characteristic indurated, circular, punched-out appearance 
of the specific venereal sore. “ It is a bold surgeon,” says Mr. Hutch- 
inson, “ who makes the diagnosis of hard chancre before the secondary 
symptoms appear.” If this be true of the diagnosis of venereal sores, how 
much more of those which occur in unusual localities ! The indurated, 
circular, non-healing ulcer, together with the enlarged, superficial axil- 
lary and clavicular nodes, will arouse a strong suspicion of its true cha- 
racter, and the appearance of the specific secondary eruption will dispel 
all further doubt. In syphilis the superficial lymphatics of the axilla and 
the clavicle become enlarged at the same time. In carcinoma it is the 
deeper lymphatics in the axilla which first become enlarged, and those 
in the clavicular region much later. 
Syphilis of the Breast. 
Secondary syphilis occurs upon the breast in the form of skin eruptions and 
mucous patches. 
The diagnosis is usually readily made in these specific skin eruptions, as they 
are present in similar forms upon other parts of the body at the same time. 
Syphilitic mucous patches sometimes form upon the inferior surfaces of the pen- 
dulous breasts of fleshy women. The anaesthesia and analgesia occasionally 
observed in the breast are regarded by Fournier as manifestations of later second- 
ary syphilis. 
The tertiary syphilitic diseases include rupia, ecthyma, mucous 
patches, and gummata. Gumma is located either subcutaneously or 
within the breast, and may be either diffused or circumscribed. The 
circumscribed gumma, far more frequently than the diffuse, develops 
without much or any pain, and is often discovered by accident. The 
gumma gradually increases in size, becomes adherent to the skin, which 
in turn is reddened, softened, and finally gives way, and the contents 
of the gumma discharged. Healing usually takes place promptly. The 
remaining scar has a characteristic deep copper-colored stain. Great 
difficulty in the diagnoses of tertiary syphilitic affections, especially 
gumma from malignant tumor, often arises, and no doubt gummatous 
breasts have been removed under the mistaken idea that they were 
cancerous. The lesions of syphilis are usually multiple; the initial 
lesion of cancer is single. Syphilitic affections are commonly very HYPERTROPHY. 
573 
chronic in their history, and improve rapidly under vigorous anti- 
syphilitic treatment. Carcinoma, on the other hand, is progressive, 
shows no tendency to recover, and does not improve under antisyphilitic 
treatment. 
Treatment.—Syphilis is the most amenable to treatment of all the 
chronic diseases. Mercury by inunction, or gray powder in grain doses, 
is recommended by Mr. Hutchinson. Iron and arsenic with the mer- 
cury, in the anaemic and feeble, is the treatment to be followed in the 
secondary stage. In the tertiary stage mercurial inunctions and iodide 
of potassium in increasing doses, combined with essence of pepsin or 
bitter tonics, continued for a length of time, give the best result. 
Neuralgia of the Mastodynia. 
A painful affection of the breast occurring, according to Gross, most 
frequently in young unmarried women from puberty to twenty, though 
it may occur at any time after puberty. The pain is often most violent 
and out of all proportion to the local condition which may be found 
present. Indeed, some of the most severe cases have occurred in women 
in whom no tumor or other cause for the pain could be discovered, 
even when the breast was explored by incision. The affection usually 
occurs in women who have had some pelvic disturbance and are of a 
hysterical type. In certain cases, however, small tumors may be felt, 
and Velpeau makes a classification of painful breast, as follows: (1) 
Neurotic tumors and nodosities; (2) Neuralgic pains without tumors; 
(3) Imaginary tumors. 
In cases where painful nodosities occur the pain is out of all proportion to the 
size of the tumor, nor is the pain constant in this or any of the varieties of masto- 
dynia, but periodical, occurring either at certain periods of the day or, as often 
happens, just before and during menstruation. The cases in which there are severe 
neuralgic pains without any tumor are the most numerous. The pain often radi- 
ates into the arm and down along the sides of the thorax. According to Billroth, 
Eulenberg, and others, this affection is an intercostal neuralgia with radiation 
toward the. anterior part of the thorax. 
The treatment of mastodynia, especially those cases in which no 
tumor is present, is most unsatisfactory. So far, it can only be said that 
the pain in some cases diminishes greatly and disappears with the cessa- 
tion of the menses. Any disturbance or disease of the pelvic organs 
should be looked to and corrected if possible. Local application of 
lotions, salves, and the like are not to be recommended. A very useful 
practice, in severe cases, is strapping of the breasts with adhesive plaster. 
Not only does this produce equable pressure upon the breasts, and thus 
relieve the pain, but prevents the patient from applying dirty salves 
and from handling the breast, and thus aggravating the condition. 
Hypertrophy of the breast is a very rare form of enlargement of 
this gland. In nearly all the cases observed it has affected both breasts, 
and has occurred in young women, one case at the age of fourteen years. 
There seems no well-defined cause for the enlargement. The hyper- 
trophy begins with menstruation; the growth is very rapid during the 
Hypertrophy. 574 
SURGICAL DISEASES ANI) INJURIES OF T1IE BREAST. 
first few months, and after that is very slow. The increase in volume 
takes place in all parts of the breast, and is a diffuse hypertrophy of 
the normal glandular and fibrous connective tissues of the breast. The 
weight becomes a burden, incapacitating the patient from work, and by 
the excessive nutritive activity taking place in the gland the general 
nutrition is bad. Pregnancy seems, in one case at least, to have had a 
favorable action upon the growth, arresting it, and a decided diminution 
in the volume of the breast was noted. No known remedy nor method 
of treatment has any appreciable effect to arrest or prevent the process, 
although a multitude of remedies, reasonable and ridiculous, have been 
suggested and tried in this condition. 
Tumors of the Breast. 
Nearly all varieties of tumor occur in the breast, not only in simple 
structural types, but also as mixed tumors; thus, a glandular tumor 
may be composed very largely of fibrous tissue as well as glandular 
elements, and is then known as a fibro-adenoma. In this tumor may 
develop cysts in the course of cystic degeneration, and it is then desig- 
nated as a fibro-cysto-adenoma. Degenerations are much more com- 
mon in malignant tumors, particularly the sarcomata; thus we have 
cysto-sarcoma as the result of cystic degeneration or melano-sarcoma as 
the result of pigmentary degeneration. Williams finds that nearly one- 
fifth of all tumors, both innocent and malignant, occur in the breasts, 
and that one-fourth of all carcinomatous tumors have their initial seat 
in these glands, and still further it may be stated that 92 per cent, 
of all breast-tumors are cancers. The word cancer is here used as 
elsewhere in this article in its clinical significance, as equivalent to 
malignancy, without reference to the particular variety of malignant 
tumor. 
Cysts number less than 2 per cent, of all tumors found in the breast. 
They occur as both single and multiple tumors, and quite frequently are 
found in both breasts. They contain serous, mucous, often brownish 
fluid, often milk more or less changed. Others contain a clear lymph 
fluid, and a rare form of cysts are the hydatids. Cysts vary in size, 
from those containing but a few drops of fluid to those containing a pint 
or more. As a rule, however, the cysts of the breast only exceptionally 
reach such dimensions. True cysts of the breast may be divided into— 
first, retention or glandular; second, lymphatic ; third, hydatid cysts. The 
greater number belong to the first class, the retention-cysts. The lymph- 
cysts are very rare—only some 16 or 20 cases were lately collected 
—while hydatid cysts are even more rare. 
Retention-cysts are due to obstruction to the ducts or secreting acini, 
caused by imperfect development of the ducts, injury and disease of the 
nipple, or inflammation about the ducts and their subsequent contraction. 
The obstruction is not always complete, as often a quantity of cystic 
fluid can be squeezed out of the nipple. Retention-cysts are often 
classified, according to their contents, into (a) serous, mucous, sanguino- 
lent cysts; (6) lacteal or galacteal, occurring during lactation or after- 
ward, containing milk more or less changed, resembling butter and oily 
substances. TUMORS OF THE BREAST. 
575 
These cysts produce no special pain or other unpleasant symptoms, but from 
their presence give rise to great uneasiness on the part of the patient through 
dread of carcinoma. No doubt, cystic breasts have been sacrificed under a mis- 
taken diagnosis of malignancy, for it is not always possible to make a correct 
diagnosis from the symptoms above. Fluctuation is not usually present, owing to 
the tension and thickness of the cyst-walls and the depth within the breast at 
which it is placed. No fluid can ordinarily be pressed out of the nipple, and, to, 
still further add to the difficulties of diagnosis, the nipple is occasionally retracted 
and the axillary nodes enlarged, as noted by Paget. The first appearance of the 
tumors at or following lactation, the fact that they are multiple and present in both 
breasts, and remembering that the nipple is not nearly so frequently retracted in 
cysts as in cancer, or the axillary nodes enlarged, the skin not adherent, the 
tumor movable, and the growth slow, all point to non-malignant tumor, and the 
elasticity would suggest fluid. An exploratory puncture will be necessary to 
make the diagnosis absolutely certain. On the other hand, the diagnosis is com- 
paratively easy in the larger single cysts placed near the nipple or superficially, 
when the sense of fluctuation can be made out more or less distinctly. 
The treatment in these cases is to evacuate, incise the cyst under aseptic pre- 
cautions, and pack the cavity lightly with iodoform gauze. When the cysts are 
Fig. 248. 
Transection of an adenoma of the breast removed from a woman twenty-two years old, showing 
the well-defined capsule, the fibrous stroma, and the foci of proliferated glandular tissue, 
varying in size, and surrounded by distinct walls of stroma which form compartments (from 
the'gross specimen preserved in formalin solution, natural size). 
very small and numerous it is needless to say they should not be disturbed. If 
they enlarge and the mass of the breast become an annoyance, amputation in such 
cases would be indicated. 
Adenoma or glandular tumor (the “ chronic mammary tumor ” of 
Sir Astley Cooper) develops in the breast usually after puberty. This 
neoplasm differs from hypertrophy mainly in the fact that it affects sin- 
gle lobules or portion of lobules, and not the entire breast (Fig. 248). 
By reference to the figure it will be seen that the tumor has a distinct capsule, 
and within is seen the tumor-tissue still retaining the outlines of the lobules. The 
microscopic characteristics of this tumor are well shown in Fig. 249, taken from a 
section of Fig. 248. The tumor is seen to consist of a fibrous connective-tissue 
stroma enveloping the glandular elements. In this particular specimen the amount 
of fibrous connective tissue is excessive. Tumors showing a larger amount of 
cellular elements are known as acinous adenoma when the cells of the acini pre- 
dominate, and a tubular adenoma when, on the other hand, the cells from the ducts 
are in excess. When the fibrous stroma is in excess of the glandular elements, as 576 
SURGICAL DISEASES AND INJURIES OF TIIE BREAST. 
is most frequently the case and as the drawing shows, it is known as a fibro- 
adenoma. Not infrequently the acini and the ducts are dilated into cysts of vari- 
ous sizes; such a tumor is known as a cysto-adenoma. 
Adenoma is rarely observed before puberty or after the menopause. 
These tumors seem, therefore, to develop during the functional activities 
of the organs. The growth is usually slow and painless. The tumor 
Fig. 249. 
A section of the adenoma shown in Fig. 248, taken from the border of one of the glandular foci, 
showing the dense connective-tissue stroma, and the glandular tubules lined with several 
layers of epithelial cells and cut in various directions. A few small blood-vessels in cross-sec- 
tion are also apparent. (Tissue fixed in formalin solution; section stained with formalin 
methyline blue. Leitz, obj. 3, ocular 4 (A. P. Ohlmacher).) 
lias a hard, bossy feel, often nodulated. Owing to its great tendency to 
cystic degeneration it often has an elastic, semi-fluctuating feel. The 
tumor has a capsule and is thus freely movable. 
The chief diagnostic signs of adenoma are its hard, nodular feel, 
slow growth, mobility within the breast, not adherent to the skin, no 
retraction of the nipple or enlarged lymph-nodes, a slight discharge at 
nipple upon squeezing the breast, and the patient about thirty. 
Sarcomata are rare as compared with carcinoma, forming but 7 per 
cent., and carcinomata 85 per cent, of the malignant tumors of the breast. 
The round, the spindle, and even the giant-celled sarcomata have been 
observed as occurring in this gland. More frequently the sarcoma-cells 
invade a fibroma or adenoma and form a fibro-sarcoma or adeno-sar- 
coma, or, infiltrated with pigment-cells, a melano-sarcoma. These mixed- 
celled sarcomata frequently undergo cystic degeneration, and are then 
known as fibro-cysto-sarcomata. Sarcoma rarely occurs before puberty 
or after thirty. The tumor becomes voluminous, though the growth at 
first may be slow. The skin is stretched and shiny, of a dark reddish- 
brown color with blue veins showing through. The entire gland may 
be involved in the growth, the so-called sarcoma en masse, or the tumor 
may develop in certain parts of the gland at about the same time. In TUMORS OF THE BREAST. 
577 
the former case the tumor is uniform and the skin stretched smoothly 
over it; in the other the numerous points of growth give a nodular cha- 
racter to the breast. 
Sarcomata have been mistaken for abscess, owing to the redness, rapid growth, 
sense of fluctuation, and pain attendant upon the growth, and have been punctured 
under the supposition that they were abscesses. The history of a recent pregnancy 
or lactation, the rise of temperature, and distinct fluctuation point to abscess- 
formation. In making the examination it is well to remember Codes’ law, that 
the wider the area over which fluctuation can be felt the more certain is the pres- 
ence of fluid. But in case of doubt an exploratory puncture will reveal the true 
character of the mass. From carcinoma the distinction is still more difficult, and 
the microscope must in many cases determine the exact character. 
Age.—Sarcomata occur usually before thirty; carcinomata are rare 
before thirty. The skin is stretched, shiny, and reddened, and not early 
adherent to the sarcoma. In carcinoma the skin is early infiltrated and 
adherent, pale, blanched, and puckered. Axillary nodes are not enlarged 
in sarcoma : there is always an early enlargement in carcinoma. In 
the cut section of a sarcoma there is an absence of adipose tissue, this 
having been transformed into sarcomatous tissue. In carcinoma there 
is always considerable fatty tissue present (Cornil and Ranvier). 
Carcinoma of the breast occurs under two histological forms—acinous 
and tubular, according as the primary growth develops in the acini or 
tubules. ( Vide Carcinoma, Chapter XXVI. Vol. I.) In the acinous 
variety the carcinoma cells are closely packed in the alveolar spaces and 
Fig. 250. 
A scirrhous carcinoma of the male breast of one year’s duration, removed from a patient fifty- 
one years of age. Photograph of gross alcoholic specimen somewhat reduced in size. At a the 
shrunken and retracted nipple; the dark-colored area b represents the ulcerating surface of 
the tumor; while c marks the incision made for obtaining tissue for microscopical examination. 
surrounded by a connective-tissue stroma. The cells are large, irregu- 
lar, spheroidal, and multinuclear, showing a large amount of granular 
matter within the cell-body and frequent mytoses in the nuclei of the 
cells. 578 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
The amount of stroma forming the alveolar spaces and the rapidity of the 
growth of the tumor determine the clinical variety. If, as is most frequently the 
case in carcinoma of the breast, there be an abundance of stroma and a slower 
growth, the tumor is known as a scirrhous, hard, or chronic carcinoma. If, on 
the other hand the tumor develop rapidly, with a small amount of alveolar stroma 
and an excessive proliferation of the cells, the tumor will have a soft, elastic feel, 
and is known as encephaloid, soft, or acute carcinoma (Fig. 252). Carcinoma cells, 
and the stroma as well, are subject to colloid degeneration: when this occurs the 
tumor is known as a colloid carcinoma. This form of degeneration most frequently 
follows in the soft or acute carcinoma. 
Tabular carcinoma occurs much less frequently than the acinous 
variety, and develops from the tubules or excretory milk-ducts. 
Injury or inflammation of the ducts or the degeneration of a cyst- 
wall is frequently the origin of a tubular carcinoma. 
Fro. 251. 
A section from the tumor shown in Fig. 250, showing the large amount of dense connective-tissue 
stroma surrounding the irregular islets of epithelial (carcinomatous) cells. An actual necrotic 
destruction of the epithelial cells is taking place. The protective and inhibitory influence of 
the connective-tissue overgrowth occasionally seen in scirrhous carcinomata was shown in 
this case by the slow growth of the tumor and by the absence of metastases in the axillary 
lymph-nodes of the affected side. (Tissue fixed in formalin solution; section stained with 
formalin-safranin. Leitz, obj. 7, ocular 4.) 
Symptoms of Carcinoma.—The “scirrhous” variety is by far the 
most frequent, and usually begins in a hard nodule located in the periph- 
ery of the breast. Statistics seem to prove that the largest proportion 
develop in the upper outer quadrant of the breast. The next most usual 
position is about and below the nipple and areola. Apparently the left 
breast is more often affected than the right; but what is of much more 
importance is the fact that in only 2 cases out of 869 were both breasts 
simultaneously affected with beginning carcinoma. When any neoplasm, 
therefore, develops in both breasts at the same time, there is very strong 
evidence that it is not carcinoma. The primary nodule of carcinoma is 
often discovered accidentally by the patient in the bath or while she is 
dressing. Pain, which sooner or later becomes a distressing symptom 
of all forms of carcinoma, is often entirely absent in its earlier stages. TUMORS OF THE BREAST. 
579 
When the nodule is once discovered, the patient, overcome with a dread 
of cancer, often complains of pain in the seat of the tumor where just 
previously none had existed. 
The growth of carcinoma is rapid compared with that of benign tumors. A 
carcinoma grows perceptibly in from three to six months. The volume of the 
tumor is, however, not great: in scirrhous and colloid carcinoma, in fact, the bulk 
of the tumor is often less than the portion of the breast displaced by the tumor. 
In the growth of carcinoma there is a twofold cellular proliferation—(1) the mul- 
tiplication of carcinoma-cells within the alveolar spaces; and (2) the area of 
small-celled infiltration at the growing margins of the tumor. These latter cells 
resemble embryonic connective-tissue cells, and form a considerable proportion of 
the bulk of the tumor. 
By this infiltration of the tissue with young cells the tumor becomes 
fixed and immovable. This fixation is an early and important sign of 
Fig. 252. 
A small portion of a section of a rapidly-growing soft carcinoma of the breast of a woman forty- 
seven years of age—the so-called “acinous carcinoma” of Billroth—showing the great abun- 
dance of polymorphous epithelial (carcinomatous) cells, with the very sparing amount of con- 
nective-tissue stroma. In three of the carcinomatous cells karyokinetic nuclear figures are 
prominent as dark masses. (Tissue fixed in Flemming’s chromic-acetic-osmic-acid mixture; 
section stained with Pfitzner’s safranin solution. Leitz, objective 7, ocular 4.) 
carcinoma, It is a fixation of the tumor itself, and any mobility made 
out by manipulation of the tumor is a motion of the whole breast, and 
not of the tumor moving within the breast. Coincident with the cellu- 
lar growth of the carcinoma a degeneration of the cells within the 
alveoli occurs, with the retraction of the connective-tissue stroma. This 
tendency to contraction occurs very early in carcinoma, and when the 
initial lesion is seated in the superficial portion of the breast there is a 
marked retraction and dimpling of the shin (pig-skin appearance). This 
is not due primarily to the infiltration of the skin by carcinoma-cells, 
but rather to the contracting tendency of the tumor, drawing in the 
Hgamenta suspensoria. In nearly 50 per cent, of all carcinomata the 
nipple is retracted and drawn in by the contraction of the connective- 580 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
tissue stroma about the milk-ducts. Thus, carcinomata developing in 
and about the nipple are much more liable to produce this symptom 
than those placed remotely at the periphery of the gland. As retraction 
of the nipple rarely occurs in non-carcinomatous conditions (5 per cent., 
according to Gross), this symptom becomes of importance in determin- 
ing the malignancy of the growth when it is present. But as it is not 
the earliest symptom, and may be absent altogether, and does occur in 
conditions other than cancer, it is not as important a sign of carcinoma 
as is generally supposed. Somewhat later the skin becomes adherent 
to and infiltrated with the carcinomatous elements. This adherent, 
retracted, pale, and dimpled skin is a very important symptom of cancer. 
Fig. 253. 
Advanced scirrhous carcinoma of eleven years’ duration in a woman of sixty years. A superficial 
ulcerating process has begun in the skin overlying the tumor, and a considerable bulk of the 
protruding tumor is composed of a fluctuating mass of puruloid material ready to break 
through the surface. The axillary nodes are extensively involved. 
Carcinoma often disseminates itself most rapidly through the lym- 
phatic vessels of the skin. The points of secondary deposits appear as 
small hard, shot-like nodules in the skin. These nodules rapidly develop 
—so rapidly, indeed, that the skin assumes a dusky red, inflamed appear- 
ance, and coalesces into a flat plate-like mass, the squirrhc en masse of 
Velpeau. Not only does the carcinoma involve the skin, but it becomes 
adherent to all the adjacent tissues. In certain cases the entire chest- 
wall is so infiltrated with the carcinoma-cells that it is hard and board- 
like, and the ribs so fixed that the respiratory movements on that side 
are interfered with. Velpeau gave to this particular form the name of 
cancer en cuirasse. It is not to be regarded as a separate variety of car- 
cinoma, as has been done by some writers (Fig. 253). TUMORS OF THE BREAST. 
581 
The atrophic cancer of Billroth is not a distinct variety. A degen- 
eration of the alveolar cells takes place early in all carcinomata. In 
scirrhous or chronic carcinomata, in which the growth of the tumor 
is relatively slow, there is ample time for an amount of absorption of 
this material as well as connective-tissue organization, and the alveolar 
spaces become filled with whorls of connective tissue. Usually the 
tumor is advancing at some other point while these atrophic changes are 
taking place, so that it is not by any means true that carcinoma is a self- 
limited disease and effects a spontaneous cure in this manner. 
Fig. 254. 
Same as Fig. 253. 
The writer saw at the London Hospital a woman in whom such atrophic 
changes had been taking place for eighteen years. All outline of the breast had 
long since disappeared, together with the nipple and areola, and only a hard, 
brown, leathery mass, firmly adherent to the ribs, remained. Successive visiting 
surgeons from the time of Mr. Curling and the elder Adams had proposed opera- 
tion, which had been resolutely declined, and she was when seen earning her living 
as a laundress. 
The Lymphatics.—The lymph-nodes are very early involved : those 
of the axilla are usually the first to be affected in carcinoma of the 
breast. The axillary nodes have been found enlarged and containing 
secondary carcinomatous deposits in every case where the axilla has 
been thoroughly explored in the operations upon the breast. They may 
be so small that it is impossible to detect them before the operation, but 
their presence will be revealed during the dissection. The lymphatics 
may be enlarged from simple irritation or inflammation, but in such 
cases may be felt as separate, distinct nodules. Lymph-nodes contain- 
ing secondary carcinomatous deposits are very hard, matted together, 582 
SURGICAL DISEASES ANI) INJURIES OF THE BREAST. 
and indistinguishable from each other. In carcinomata located on the 
sternal side of the breast the secondary deposits would first appear in the 
mediastinal nodes, a condition which can only be surmised. When the 
tumor is placed near the nipple not only the axillary nodes, but the 
infraclavicular, are early involved. Dr. Halsted finds that in nearly all 
cases where he has removed the supraclavicular fat and lymphatics a 
microscopic examination has shown the presence of carcinomatous cells. 
On making with a knife a section of suspected tissues which have been pre- 
served in alcohol or 2 per cent, formalin solution, the cancer-tissue, if present, 
appears blanched and white, in marked contrast to the surrounding tissues. 
Diagnosis.—The first question to which an answer must be given 
in a case of tumor of the breast is, Is it innocent or malignant f The fol- 
Fig. 255. 
Recurrent carcinoma eight months after incomplete operation in a woman seventy-five years of 
age, showing the extensive nodular, ulcerating surface surrounded by cancerous masses 
under the skin. The oedema of the right arm from the circulatory obstruction occasioned 
by metastatic growths about the axillary vessels is well shown. 
lowing are among the most important points to be considered in arriving 
at a differential diagnosis: Age.—Innocent tumors appear at any age, 
as do the malignant neoplasms, but innocent tumors are more apt to 
occur at puberty and during pregnancy and lactation. Of the malignant 
tumors, sarcoma occurs before thirty; carcinoma, which is the most 
common tumor of the breast, is very rare before twenty-five, not com- 
mon before thirty-five, and most common from forty to fifty. This is 
known as the cancer 'period. Skin.—Innocent tumors do not become 
adherent to the skin (unless the tumor undergoes some degeneration or 
inflammation, which is most unusual). Malignant tumors involve the TUMORS OF THE BREAST. 
583 
skill early. Either the skin becomes stretched, shiny, red, and brawny, 
with large veins showing upon its surface, as in sarcoma, or it is 
retracted, pale, and pitted, as in carcinoma. Growth.—The growth of 
an innocent tumor is always slow, pushing aside the normal tissues, from 
which it is separated by its capsule. The growth of a malignant tumor 
is rapid, infiltrating the tissues without any capsule or limiting mem- 
brane. Mobility.—Innocent tumors are usually freely movable, owing 
to their capsule and method of growth. Malignant tumors early become 
fixed and immovable (there is often an apparent mobility in carcinoma 
which is not real), and tumors which seemed movable on examination 
are often at the operation found firmly adherent to the subjacent tissues. 
Pain.—Innocent tumors are not usually 
painful; pain becomes, sooner or later, a 
prominent symptom in all cases of cancer. 
The pain, being a subjective symptom, must 
be taken with great caution. The patient 
upon discovering a lump in the breast 
usually experiences some pain from that 
moment, although there has been no pain 
before, and with every evidence that the 
mass had been there for some time. There 
may be no pain in the earlier stages of a 
malignant tumor, but to wait for the ap- 
pearance of pain as an essential sign of 
cancer would be to permit the period in 
which the patient could be saved by ope- 
ration to slip away. 
Secondary affections do not occur in the 
growth of innocent tumors, while they 
always occur, and usually very early, in 
all malignant tumors. When lymphatic 
enlargement does occur in connection with 
the growth of innocent tumors, it is the 
nature of an hypertrophy of the normal 
cellular elements, and not a heterologous new growth, as takes place in 
malignant growth. The hypertrophied nodes may be felt separate and 
movable, while those containing cancerous deposits are matted together 
and feel hard and nodular. 
Metastasis.—Innocent tumors never form secondary deposits in other 
organs. Malignant growths do form such deposits very frequently ; 
most important, however, is the fact that these metastases in other organs 
may occur very early in the development of the tumor, and are not 
infrequently cause of death, even after the most careful and complete 
local removal of the growth. 
Cachexia.—Innocent tumors do not affect the general health, except 
mechanically. With the growth of malignant tumors cachexia is always 
developed. 
Fig. 256. 
Cancer of male breast (Park). 
By attention to these different points the question of malignancy or non-malig- 
nancy may be determined in many cases. But in the very early stages of cancer, 
when the tumor is small, before the skin has become adherent over the tumor or 
the axillary nodes enlarged, or pain or evidence of rapid growth can aid in the 584 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
differential diagnosis, and the age of the patient under forty,—in such cases it is 
impossible by the symptoms alone to make the diagnosis certain. To affirm that 
in all such cases the breast should be removed would be to sacrifice breasts which 
could be saved. As the microscopic examination is, after all, the final test of the 
character of the growth, it is far better to make this examination before the re- 
moval. The microscopist must be competent and conservative, as well as the sur- 
geon ; and if one examination is not satisfactory, a second trial specimen should 
be secured and examined. The instruments which have been devised by various 
operators in the form of harpoons, hooks, and punches to secure a trial-piece of 
the tumor are quite inadequate. The fragment obtained by such means is insuffi- 
cient to examine the cells in their relations, and the operator can never know that 
he has secured a piece of the growth itself. It is far better to make an exploratory 
incision into the doubtful growth, examine the cut edge macroscopically, and 
secure a piece, including the growing edge, large enough to make sections. This 
preliminary operation may be done under general or local anaesthesia. Complete 
local anaesthesia can be secured by following the method of Dr. C. L. Schleich. 
This consists of injecting into the true skin a solution of cocaine, composed of 
cocaine hydrochlorate gr. jss; morphine hydrochlorate, gr. 1.8; sodium chloride, 
gr. 3; sterilized water, The needle is introduced into the true skin at the 
desired point and a small quantity of this solution injected. The needle is with- 
drawn and introduced again, obliquely through the edge of this now anaesthetic 
area, and a second circle of anaesthesia is formed. When a sufficient superficial 
area has been rendered anaesthetic the needle is introduced into the deeper tissues, 
and even into the tumor itself, and the tissues injected full of the fluid. By this 
method, carefully carried out, complete anaesthesia is secured and the exploratory 
incision and the section removed without pain to the patient. 
Operations upon the Breast. 
As in every surgical operation, the patient, the operator, his assist- 
ants, instruments, and dressings should be prepared in accordance with 
the principles of the most rigid asepsis. These details, having been 
Fig. 257. 
Diagram showing skin-incisions : triangular flap of skin, ABC, and triangular flap of fat (Halsted). 
repeatedly given in other portions of this work, are omitted here. As 
the hair of the patient’s head is often the source of wound-infection, the 
head should be enveloped in a moist bichloride towel-turban, and a 
sterilized sheet thrown over the face and neck and fastened to the apron OPERA TIONS UPON THE BREAST. 
585 
of the anaesthetizer, and the anaesthetic administered beneath this. The 
arm on the affected side is drawn well outward and upward, enveloped 
in sterilized towels, and given over to an assistant. The thorax and 
portions of the body not in the field of operation are to be protected by 
a mackintosh covered with sterilized towels. As the anaesthetic has to 
be given under a sheet and maintained for a long time, ether, when not 
contraindicated by organic disease of the kidneys or lungs, should be 
administered. Some experiments in the use of chloroform combined 
with pure oxygen have proved it to be a very satisfactory combina- 
tion. The patients are brought under the anaesthetic in from six to 
ten minutes; the anaesthesia is easily maintained—no vomiting, no 
Fig. 258. 
Breast and pectoral muscle completely separated from thorax; axilla exposed (Halsted). 
dangerous interruptions to respiration or heart or pulse, no cyanosis, 
diminished shock, and patient recovers from the anaesthetic state without 
delirium. 
The Operation on Innocent Tumors.—The character of the opera- 
tion will depend somewhat upon the position and number of innocent 
tumors present. If the tumor is single and situated within the gland, 
the incision should be made along the groove at the lower border of the 
breast. The gland is raised and the capsule of the tumor opened, and 
the tumor enucleated, the breast replaced, and the wound closed with 
fine marginal silk suture. In some cases a narrow gauze drain for a 
few days may be necessary. If the tumor is located in the upper, outer 
quadrant of the breast, the incision may be made along the pectoral 
muscle and the breast raised and the tumor removed. By this method 
of Thomas there is the least injury inflicted upon the secreting structures 
and the avoidance of a prominent scar on the breast. If the tumor is 
very superficial, as lipoma, or so placed that it cannot be reached with- 
out too extensive disturbance of its anatomical attachment, a straight 
or curved incision may be made directly down upon the tumor and its 
removal effected. 586 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
Operations on Malignant Tumors. 
Distinct advance in the surgical treatment of malignant growths has been 
secured by the earlier and more complete removal of the primary tumor and all 
the infected tissues. The opening of the axilla in every operation for malignant 
disease of the breast marks a most distinct advance in their treatment. The 
removal of the supraclavicular lymphatics and fat, as suggested and practised by 
Dr. Halsted in suitable cases, is another step in the direction of completeness. 
The practice of Volkmann of removing the infected pectoral fascia gave him the 
best results of his time, and, with few exceptions, of all time. The removal of the 
greater portion of the pectoral muscles with their fascia, and the removal of the 
supraclavicular nodes and fat, together with a thorough removal of the contents 
of the axilla, have given the very best results obtained. 
No operation upon the breast can be too extensive if infected material 
remains to be removed, and as the operation described by Dr. Halsted 
is the most complete and extensive, we shall give, in substance, an out- 
line of the steps of the operation as he performs it: The external 
incision (see Fig. 257) extends in a wide curve from the middle of the 
upper portion of the arm out over the chest and edge of the sternum 
well beneath the nipple, and upward, following the curve of the breast 
to meet the first incision. This incision should be carried at once 
through the skin and superficial fat. The triangular flap, a b c, of skin, 
free from all fat, is dissected down to the inferior border of the pecto- 
ralis major muscle. The separation of the pectoralis major muscle 
from its costal origin is now begun and carried upward, the costal 
portion being separated from the clavicular out to the apex of the 
axillary cavity. At this point an incision is carried up to the 
clavicle through the muscle and skin, exposing thus the apex of the 
axilla. Any fascia made accessible upon the under surface of the 
pectoralis major is now carefully dissected away. The pectoralis major 
is next severed from its humeral attachment and reflected with the 
breast-mass. The fascia over the pectoralis minor is dissected away, 
and this muscle divided in its middle and reflected back and held by a 
broad blunt retractor. The axillary vessels are exposed and carefully 
separated from the mass of fat and nodes occupying the space, com- 
mencing at the very apex and working downward, and continuing the 
dissection to the subscapular vessels. Every particle of fat and fascia 
is to be removed. 
During the various steps of the dissection hsemostats should be used freely, 
grasping each end of a vessel as it is severed, or, better, severing the exposed 
vessel between two haemostats. The delicate vessels within the axilla, branches 
of the artery and vein, are to be ligated at once with silk, care being taken not to 
include any fat within the knot. Every care should be taken throughout the 
operation to prevent loss of blood. The operation is completed by severing the fat 
along the base of the skin-flap first raised. By this method the entire breast, fat 
and lymphatics, fascia and muscles, are removed in one mass. No incision is niade 
into the cancerous growth itself or into the lymphatics, and the ever-present 
danger of inoculation by the liberation of cancer-cells is obviated. 
The next step in the operation is to remove the supraclavicular fat 
and lymphatics. This may not be absolutely necessary in those cases 
which are operated very early, before the axillary lymphatics are in- 
volved. But most cases do not come to the surgeon until a much later 
period, and it will be, with suitable exceptions, a safe rule to follow. 
The incision is continued upward from the clavicle over the supra- OPERATIONS ON MALIGNANT TUMORS. 
587 
clavicular triangle to the border of the middle of the sterno-cleido- 
mastoid muscle. The internal jugular vein is exposed at the inner side 
of the triangle, and all the fat and lymphatics removed from within 
outward, down to the clavicle and outward to the outer border of the 
triangle. 
The edges of the incision are brought together by a purse-string 
silk suture, including only the base, however, of the triangular flap. 
This flap is attached so as to furnish a lining for the axilla. Drainage 
is ordinarily unnecessary. Healing is usually by first intention. The 
central portion of the wound, which cannot be brought together, often 
heals under the blood-clot; and if regular granulation forms, this sur- 
face can be quickly covered by skin-grafts after the method of Thiersch. 
The impairment of movement in the arm is very much less than would 
be imagined from so extensive removal of muscle. 
Many operators do not consider it necessary to make so extensive a dissection 
in removing the breast, and think the removal of the supraclavicular node is 
only necessary in exceptional cases. Dr. Halsted states that in 7 favorable cases, 
where the tumor was recent and small and the nodes only slightly enlarged, after 
the removal of considerably less tissue than in the above-described operation, he 
had 3 local recurrences, whereas in a series of 50 complete operations, many of 
them much less favorable from the extent of local infection, there were also but 3 
local recurrences. This statement alone is sufficient encouragement to the opera- 
tor to master the technique of the operation by practice upon the cadaver, and to 
carry it out completely in every case of malignant disease of the breast. 
Prognosis.—It must be admitted that the prognoses of operations done in 
the past for cancer of the breast have been most unfavorable, according to statis- 
tics, but a few months at most being added to the patient’s life by the operation. 
This fact has become so well understood by the laity that women suffering with 
cancer of the breast have preferred to let the disease take its course, rather than 
submit to a serious mutilating operation, which offered at best but a temporary 
respite. Thanks to the labors of such men as Volkmann and the more recent 
work of surgeons in our own country, there is a definite hope of freedom from 
local recurrence in at least 50 per cent, of the cases operated. Certainly a larger 
number than this ultimately succumb to the metastases in internal organs, but for 
these the surgeon cannot be held responsible. 
In order that these favorable results may be secured the operation 
must be done early, if possible before the skin has become involved or 
the lymphatics extensively implicated, and the operation carried out 
thoroughly as described. 
Many different drugs have been suggested in the treatment of sar- 
coma and carcinoma, but not a single one has stood the test of time. 
The local application of the various caustic pastes and solutions so fre- 
quently used by irregular practitioners is not to be recommended. The 
pain inflicted is much greater than that caused by the cutting opera- 
tion, while the destructive activities of the caustic cannot be entirely 
controlled. Furthermore, it does not reach the infected nodes, and is 
therefore always an incomplete operation. 
More recently, Dr. Coley of New York has suggested a method of treating 
malignant tumors by injecting them with toxines. Coley first used a filtered 
toxine of the streptococcus erysipelatis, to which in later experiments he added 
the toxine of the bacillis prodigiosus. At the present time he uses a mixed un- 
filtered toxine of the streptococcus erysipelatis and bacillus prodigiosus. Toxines 
prepared after one or other of these forms have been tested now for three years by 
its enthusiastic promoter, as well as many other experimenters, notably Czerny of 
Germany. This treatment should only be applied in an inoperable tumor, where 588 
SURGICAL DISEASES AND INJURIES OF THE BREAST. 
from the extent of the disease or its location or the condition of the patient 
a complete operation for its removal cannot be performed. The effect of this 
treatment seems to be decidedly more favorable in sarcoma than in carcinoma. 
Coley reports 9 cases of probable cure at periods from six months to three and a 
half years after treatment, out of 38 cases of inoperable sarcoma. No report of 
a cure of a case of carcinoma by this method has yet been made, though a stay of 
growth, and even a temporary diminution in the size of the tumor, have been 
reported. The use of cancer serum, together with the toxine of the streptococcus 
erysipelatis, as suggested by Emmerich and Zimmerman, is still too recent to 
make any statement of its possible value. As it seems pretty well established 
that the mixed toxines have the distinct effect of diminishing the volume of sar- 
comata, would it not be excellent treatment to use them after surgical removal of 
sarcoma in order to destroy any foci of cells which may have been left behind, 
and thus diminish the danger of a recurrence? Thus far, it must be confessed, 
the results obtained are very unsatisfactory, and the method itself must be held 
sub judice. But even if these methods should prove quite inadequate, may we not 
hope that along these lines of experimentation some method of treatment may be 
found by which such fearful mutilations as amputation of the breast may no 
longer be necessary, and humanity spared the anguish and suffering of malignant 
disease? ( Vide also Appendix to Chapter XXVI. Vol. I.) CHAPTER XV. 
AMPUTATIONS. 
By Rudolph Matas, M. D. 
An operation by which a limb or part of the body is removed by the knife or 
other means is an amputation. In this chapter only the amputations of the 
extremities will be considered. 
Classification.—Into typical, when an amputation is performed 
according to established rules or methods ; atypical, when the procedure 
adopted is irregular and without regard to fixed precedent, with the 
view of meeting anomalous or accidental conditions. When a limb is 
removed at a joint it is an amputation in contiguity or disarticulation; 
when the section of the limb is made elsewhere than at a joint it is an 
amputation in continuity. Amputations have been classified according 
to the time or period when the operation is performed, thus: (1) Imme- 
diate, before reaction from shock, usually within the first twelve hours; 
(2) primary, after reaction, but before inflammation; (3) intermediate, 
after inflammation, but before suppuration; (4) secondary, after suppura- 
tion has been fully established. For all practical purposes these four 
periods can be reduced to the primary and secondary—i. e. (a) after 
reaction, before infection; and (8) after infection. 
General Indications. 
In general terms an amputation is indicated when a part of a limb 
can be saved, or when life can be preserved or prolonged or made bear- 
able, by no other means. The conditions that call for amputation have 
been enormously restricted since the advent of antisepsis. The most 
frequent and urgent indications for amputation are furnished by—(1) 
the violent traumatisms which result from railroad, machinery, and 
other accidents, which cause extensive and irreparable damage to the 
soft parts and bones; (2) when the physical condition of the patient is 
such that a long post-operative treatment and long confinement in bed 
consequent upon conservatism, even if immediately successful, would 
leave a useless limb; (3) amputations are called for in certain patho- 
logical conditions (non-traumatic) which render an extremity totally 
incapable of performing its functions, or which permanently interfere 
with the patient’s comfort and usefulness, or which threaten his life. 
In this category may be classed the chronic diseases of bones and joints 
(tubercular osteoarthritis, osteomyelitis, tenosynovitis, etc.) which 
have resisted conservative treatment; the benign and malignant 
neoplasms that cannot be removed without the sacrifice of essential 
parts ; large circumferential ulcers which resist grafting or other treat- 
589 590 
AMPUTATIONS. 
ment, very rare at present; perforating trophic ulcers of the foot; 
spreading sepsis; intermuscular suppuration with threatening general 
infection; malignant oedema; spreading atheromatous or embolic 
gangrene ; diabetic gangrene ; aneurisms that burst in joints ; and con- 
genital or acquired deformities that interfere with the comfort of the 
patient. 
Local Indications furnished by the Injured Parts.—The avulsion or tear- 
ing away of a limb admits of no doubt. No doubt will exist when a limb at or 
below certain points is crushed so that the circulation in the distal part is impos- 
sible. Compound fractures of both the bones when badly comminuted formerly 
called for amputation; now they rarely do, unless too great length of bone is 
implicated and unless the soft tissues have suffered severe laceration. It is a good 
rule, other things being favorable, to attempt to save a limb if not more than two 
inches of the principal bone is comminuted. In attempting to estimate whether 
or not soft tissues have undergone too great injury for any conservative attempt, 
the muscular laceration should receive less consideration than the degree of injury 
to the skin. It is rare to save compound comminuted fractured limbs having slight 
laceration of the muscles, but extensive injury to the skin. One or two lacera- 
tions of the skin are not particularly hurtful; it is the complete death of the skin 
through immense pressure, as of a weight, produced by crushing of a car-wheel or 
a heavy beam or a stone. If all the muscles at a given point are pulpefied, ampu- 
tation is of course indicated. The Vessels.—There is great danger from rupture of 
the main artery of a limb, a difficulty greatly increased by subcutaneous bleeding, 
compressing all the tissues through which the collateral supply might be estab- 
lished, as by a simultaneous injury of the main vein. Serious injury to the 
femoral or brachial vessels, high up, by a compound fracture, usually requires 
amputation, but a system of vessels in the forearm or leg (the anterior tibial and 
its branches, for instance) may be entirely destroyed at a given level and yet the 
limb be saved. 
Great contusion and laceration of muscles without fracture of bone and little 
injury of the skin rarely necessitate amputation—certainly not primary amputa- 
tion. The important point is to relieve the immense tension of the skin on account 
of subcutaneous extravasations of blood-serum by immediate multiple incisions or 
punctures of the skin (after previous sterilization), to drain away the effused fluid. 
No drainage-tube should be used, not even a strip of gauze; only cauterization is 
required, as the least local pressure will usually cause necrosis of the already badly 
nourished skin, from which infection is apt to occur (Estes). 
Injury to the skin without serious injury to the deeper parts, with the excep- 
tion perhaps of the entire sole of the foot, should rarely call for amputation, 
owing to the great progress accomplished in grafting. In doubtful cases, when the 
viability of the parts cannot be determined by existing conditions, the surgeon 
must not be precipitate in his action, since there is very little danger in delaying 
the amputation as long as asepsis is maintained. 
The essential point to remember is, that in doubtful cases the delay pend- 
ing a decision is permissible, but is only made safe by the maintenance of 
the most rigid asepsis. So great is the confidence of some surgeons in 
the power of asepsis to ward off the formidable dangers of the microbial 
contamination of the injured tissues that they would advise the complete 
abandonment of immediate amputations in the primary period in all 
cases. Reel us of Paris has certainly demonstrated by his recent bril- 
liant results that it is perfectly feasible to maintain perfect asepsis even 
in the most extensive areas of dead tissues, and thus ward off the dan- 
gers of putrefaction until the natural processes have succeeded in sepa- 
rating the living from the dead parts. The advantage claimed for this 
procedure is to entirely eliminate the danger of shock, and to preserve 
more of the living and useful tissues than would be possible by a primary 
amputation performed in sound tissues. INSTRUMENTS. 
591 
Reclus and his followers recognize the fact that crushed tissues are always 
infected by germs from the skin, the clothing, or earth, and form a peculiarly 
favorable soil for the growth of such germs. Not only is the crushed limb per- 
fectly useless, but if left in place it endangers life from profuse suppuration, from 
traumatic gangrene, and from tetanus, though the last can be warded off by a 
prophylactic injection of its antitoxin. An amputation wisely arranged does away 
with all these dangers. This reasoning, he holds, was absolutely incontrovertible 
before antisepsis attained its present perfection by the thorough methods that he 
practises: there is no fear of such complications, provided the patient is seen early 
enough after the accident for antisepsis to be effective. After infection and 
putrefaction have set in, it is obvious that the opportunity for antisepsis is over, 
and the only hope of recovery lies in immediate amputation. 
The advice given by Reclus is certainly suggestive of the possibilities of asepsis, 
and emphasizes the lesson that unless the injured tissues are plainly infected 
already, the surgeon need not hurry to operate when he is in doubt as to their via- 
bility. There are certain conditions, like frost-bites, scalds, crushed wounds of the 
hands and feet, which should always be treated with the utmost conservatism, 
nature being allowed to draw the line between the living and the dead tissues in 
order to save every viable particle. 
In such cases, and in all cases in which profound shock precludes the possi- 
bility of immediate operation, or when it is not clear that the injured parts have 
been permanently devitalized, the injured area should be subjected to the most 
scrupulous antiseptic preparations. When the patient has rallied from shock and 
the death of the parts is unquestionable, there can be no advantage in waiting for 
nature to accomplish with very laborious and exhausting efforts what the surgeon 
can do in a few minutes with the knife, even if one or two inches more of tissue 
must be sacrificed in cutting through healthy tissue. In fact, the most recent and 
conclusive experience (Estes) teaches that the sooner an amputation is performed 
after the indications for the amputation are clearly formulated the better will be 
the ultimate result. 
In every case the condition of the patient, his ability to stand the 
additional shock of an amputation or to cope with the danger of exist- 
ing or prospective infection, exhausting fever, and suppuration, must 
decide the operator in his preference for an immediate amputation. 
Instruments. 
The instruments required to perform an amputation may be classi- 
fied into those for (1) the prophylactic and direct control of hemorrhage ; 
(2) for cutting, dissecting, retracting, elevating the soft parts; (3) for 
sawing the bone; (4) for suturing the flaps. 
In addition, material will be needed to—(1) ligate the bleeding 
vessels; (2) suture the flaps and approximate the soft parts; (3) to 
sponge; (4) to drain ; and (5) to dress the wound and stump. 
The 'prevention of hemorrhage is essential in order to avoid the dangers 
of acute anaemia and shock. To secure an absolutely bloodless condi- 
tion of the part to be amputated several methods of controlling the 
circulation have been devised. Of these, compression of the main artery 
with the fingers (digital compression) of an assistant may be applied in 
favorable spots. Thus the subclavian may be controlled in the supra- 
clavicular fossa by the finger applied over the skin or through an 
incision or by a mechanical contrivance—viz. a padded key ; the brachial 
by the finger over the line of the artery. The arterial supply of the 
lower limbs may be controlled by compressing the abdominal aorta on a 
level with the umbilicus by the pressure of the closed fist (Macewen’s 
method), or by mechanical compression, or by directly compressing the 592 
AMPUTATIONS. 
iliac with the finger through an aseptic peritoneal incision (McBurney 
and others). The entire circulation of a limb is most effectually con- 
trolled by encircling the root of a limb by a constricting apparatus, of 
which the simplest in an emergency is a rope or cord thrown around a 
limb and made tight by twisting it with a stick (Spanish windlass), or, 
more securely still by the use of any of the numerous tourniquets of 
which many models have been in use for centuries, of which J. L. 
Pettit’s is probably the most familiar example. All these methods of 
securing the complete local anaemia of a limb (ischaemia) have yielded in 
modern practice to some modification of the following method : 
Esmarch’s Method.—This consists in the application of an aseptic 
elastic rubber bandage over the limb after this has been suitably steril- 
ized and covered with a soft towel, wet with a bichloride (1 : 1000) or 
carbolated (2), per cent.) solution, which is wrapped around the affected 
limb. The elastic bandage is applied tightly from below upward in an 
even spiral (without reverses), and is carried as high up as is desired. 
The blood is all driven out of the vessels as the bandage is adjusted. 
Immediately above the upper terminus of this elastic roller a rubber 
band or hollow elastic tube is wound several times around the limb 
with sufficient contracting force to entirely arrest all arterial pulsation 
below it. The constrictor is then held in place by tying it or by a 
clamp (Wilson’s sigmoid clasp is the simplest of the numerous devices 
that have been introduced for the purpose). After the constricting 
band is secured the elastic roller is removed, and the limb below the 
constriction assumes a characteristic pallor which markedly contrasts 
with the healthy redness of the parts above. The operation can then 
be performed precisely as upon a cadaver, and is absolutely bloodless.1 
In applying the elastic constrictor or tourniquet at the root of the limb the 
following precautions should be observed : (1) Never apply the constrictor over 
the leg or forearm, as the interosseous vessels are protected from pressure by the 
two bones of these regions, and haemostasis must be imperfect. Always apply the 
elastic tourniquet over the femoral or humeral shafts, or at such points (the roots 
of the digits) where no vessel can escape circumferential compression; thus in the 
lower third of the femur, just above the condyle, the rigid adductor magnus ten- 
don may interfere with complete compression of the femoral. (2) In applying the 
elastic tourniquet begin by compressing the vascular or adductor side so that 
venous choking of the limb may be obviated. This precaution is especially 
important when Lister’s method is followed. (3) While encircling the limb with 
the elastic band it is necessary to avoid the repeated constriction of the same 
circle (linear constriction), as an exaggerated concentric compression may, in thin 
subjects especially, permanently paralyze the extremity by crushing the under- 
lying nerve-trunks. Therefore separate each turn of the rubber bv an intervening 
space. (4) Do not allow the constricted member to be decidedly fixed or extended 
after the constrictor is in place, for fear of tearing subcutaneously the underlying 
muscles and nerves. (5) Do not keep the constrictor much longer than an hour 
in place, because sloughing from prolonged arterial fasting and coagulation-necro- 
sis of the distal edge of the flaps is likely to result. This is especially true of 
cocaine operations, in which the constrictor is likely to be retained longer for 
anaesthetic purposes. It greatly favors the absorption of toxic chemical anti- 
septics, as shown by Wolfler’s experiments.2 
1 Esmarch has maintained his artificial anaemia in human limbs for two hours and a 
quarter without consequent necrosis. Such a length of time is positively dangerous, 
especially when dealing with inflamed and contused tissues, and should be avoided. 
2 After great losses of blood, which endanger life, Esmarch’s bandage may be applied 
to the extremities in order to force the blood in the latter toward the heart, and so avert 
threatened heart failure or cerebral anaemia (auto-transfusion). INSTRUMENTS. 
593 
Objections to Esmarch’s Method.—(1) Excessive capillary oozing, 
requiring an undue manipulation, an irritation of the injured tissues, 
and the ligature of many more bleeding points than usual. This is due 
to vasomotor paresis of the compressed area, and can be corrected by 
the stimulus of hot water applied to the cut surface and by stroking or 
superficial massage of the limb. (2) It increases the risk of septic 
embolism and of cancerous metastasis by forcing particles from the 
diseased area into the venous and lymphatic circulation. (3) It greatly 
favors the absorption of toxic chemical antiseptics, as shown by Wolfler’s 
experiments. 
These objections have led to an application of the rubber tourniquet alone 
(Esmarch’s principle), which secures satisfactory ischaemia without the preliminary 
elastic compression of the limb. Instead of applying the elastic bandage, the limb 
is held up in such a manner that the blood is drained out by gravity. While the 
limb is being held up it is stroked vigorously from the tip of the extremity (fingers 
or toes) to the trunk; the process (milking the limb) is followed by the application 
of the elastic constrictor at the root of the extremity. This method, which is at 
present known as Lister’s method, is very efficient, and, owing to its freedom from 
the objections urged against elastic compression, bids fair to supplant the typical 
Esmarch method in most cases. 
Instruments for Cutting-, Dissecting, and Retracting the Soft 
Parts.—One or two ordinary large scalpels are all-sufficient for the 
performance of modern amputations. The formidable rapier-like knives 
of earlier days have been discarded since the abandonment of the trans- 
fixion methods so popular in the pre-anaesthetic period, when security 
was so frequently sacrificed to rapidity. Nevertheless, a strong, medium- 
sized amputating knife (6-9 inches of cutting edge—Liston’s model) is 
almost a necessity in dividing the thick muscular layers and skin in a 
circular amputation of a stout subject; a long, narrow, and straight 
knife to divide the interosseous membrane and to disarticulate the 
smaller joints is required to operate with rapidity and elegance. A 
plain or rat-tooth dissecting-forceps, a stout pair of straight scissors, and 
a periosteotome to clear the bone of periosteum at the point of division, 
complete the outfit required for the division and retraction of the soft 
parts. Cloth retractors, made with stout aseptic gauze, will be required 
to protect the soft parts while the bones are sawn. 
When one bone is to be divided a small towel with a tear in the centre will 
answer the purpose. When two bones are to be divided, as in the forearm or leg, 
a broad strip with three tails (one for the interosseous space and two for the sides) 
is used ; and when the fingers or toes or their metacarpals are to be removed simul- 
taneously, a six-tailed retractor must be used. The metallic retractors recently 
recommended by McCurdy may also be used with advantage. 
For the direct control of the bleeding points a tenaculum is often needed to 
drag out retracted vessels ; but the ordinary haemostatic clamp will suffice to secure 
divided arteries until they are permanently secured with ligatures or obliterated 
by torsion. As many artery-clamps will usually be required as there are bleeding 
points. 
To Divide the Bone.—The bones are usually divided with a saw. 
A bow saw (Butcher’s model) with adjustable blades, a capital saw with 
movable back, a metacarpal saw, will usually suffice for all purposes; 
Lister’s cutting pliers, straight and bent, for division of phalanges and 
metacarpals; and gouge or rongeur forceps to nip off irregular project- 
ing ends. A lion-jawed forceps (Farabeuf’s) or osteophor may be 
needed to steady the movable end of the bone in re-amputating a stump. 594 
AMPUTATIONS. 
A Gowan-Wyeth’s exsector and Macewen’s chisels will also be useful in 
amputating by Neudorfer’s methods, and even a cliain-saw may be used 
with advantage in all cases in which it is especially important to avoid 
injuring the soft parts with the saw. 
Bleeding from the bone-marrow is usually best controlled by sutur- 
ing the periosteal flap over it. Hals ted’s catgut wool and Horsley’s 
antiseptic wax have been used to control excessive oozing, but simple 
compression and the temporary use of hot water, followed by periosteal 
suturing, are usually sufficient for the purpose. 
For suturing deep muscular layers and skin-flap the Keith or Hage- 
dorn needles are undoubtedly the best, and the McBurney-Abbe needle- 
holder will be found to be the most convenient and generally useful. 
Iu supporting heavy muscular flaps silver sutures may be required, and 
for this purpose ordinary needles threaded with silk may be used as car- 
riers. The material for suturing has been sufficiently described in 
other sections of this work, and need not be discussed here. Suffice it 
to say that fine sterile silk is still used with the greatest confidence by the 
profession, and is certainly infinitely more reliable than catgut if there 
be reason to apprehend suppuration. Catgut or kangaroo tendon answers 
well for the approximation of the deep muscles and obliteration of dead 
spaces. Silkworm cannot be excelled, and is the ideal material for 
approximating skin flaps. 
Sponges.—The sponge has been discarded in amputations, as in 
other operations, in favor of gauze mops made of sterile gauze cut 
into long strips, with which the surface is thoroughly dried accord- 
ing to the now generally accepted “dry method of Landerer.” In 
amputations through septic surfaces copious antiseptic irrigation is 
required, and here, again, the cloth mop or a towel (6 by 12 inches) 
will serve instead of the sponge, as it is thrown away and destroyed, 
and thus never exposes the patient to infection, as is likely to occur 
with the sponge. 
Drainage.—In all amputations through infected areas thorough 
drainage must be provided for. This is best secured by packing the 
stump with iodoform gauze, which is removed in a few days, when the 
surfaces may be allowed to come together if healthy. In cutting 
through sterile tissues no drainage is required if there is absolute cer- 
tainty that asepsis has been vigorously maintained and no irritant anti- 
septic irrigation has been produced. If such is the case and the dry 
sterile method of Landerer has been adopted, the deep surfaces can be 
approximated and all dead spaces obliterated by catgut or buried sutures. 
Finally, the skin-flap surfaces must be closed by interrupted silkworm 
sutures. 
If there be any doubt as to the asepsis, it is also much safer, even in healthy- 
looking wounds, to use either a short soft-rubber or a glass drainage-tube at each 
end of the stump to facilitate drainage. 
In sutures the greatest care must be exercised not to suture too closely or too 
tightly, for fear of strangulating the edges of the skin-flaps, especially in the lower 
extremities, where this risk is proportional, in equality of circumstances, to the 
distance of the cut edge from the heart. 
Dressing's.—If the stump be septic and a tampon of iodoform gauze 
be used, adjust another layer of the same gauze over the surface of the METHODS OF AMPUTATION. 
595 
stump. Then cover the whole surface with sterile gauze; then over 
this, again, a large pad of sterilized absorbent cotton sufficient to protect 
the stump from all possible mechanical injury. Finally, a bandage 
must be snugly applied. If the toe has been removed, cover the foot 
up with dressings to the ankle; if the foot itself has been removed, 
cover the whole leg and put on a splint under the knee and thigh to 
secure rest. If the leg be amputated, cover it up to the middle of 
the thigh, and also adjust a comfortable postero-lateral splint like a 
trough made of perforated tin or binder’s board, which can be easily 
moulded to the surface. The same principles apply to the upper 
extremity. 
Crede's Method.—Crede discards drainage and sutures and brings the 
flaps together by means of equable pressure with gauze bandages. In 
his cases the result was satisfactory, the stumps being in excellent con- 
dition at the end of ten days. This method can only be utilized in sep- 
tic conditions or in other states in which the vitality of the haps would 
be endangered by suturing. 
Methods of Amputation. 
From Hippocrates to the time of Celsus the surgeon simply followed in the 
wake of nature, never venturing to apply the knife for the removal of a limb 
except within the limits of the mortified tissues ; and this seems to have prevailed 
for at least four hundred years. Celsus, the prince of Greek physicians, who lived 
shortly after the time of Christ, introduced the first innovation bv cutting down to 
the bone between the living and the dead tissues. It is probable, according to the 
evidence furnished by his writings, that he was aware of the value of the ligature 
and that he applied it to control bleeding vessels. Archigenes, following closely 
after Celsus, was the first to attempt prophylactic haemostasis by applying a cord 
or band around the limb to control the hemorrhage during the amputation. With 
the fall of the Roman Empire and the advent of the long night of the Middle 
Ages the Celsian method was lost in the general darkness and the old Hippocratic 
doctrines survived, and were maintained by the all-potent influence of Galen and 
his Arabian commentators. As late as the middle of the seventeenth century 
the only haemostatic was the actual cautery and boiling oil, though Guy de Cliau- 
liac had revived the teaching of Archigenes by constricting the limb, on a level 
with a joint, with a cord which was allowed to remain in situ, to ensure not only 
haemostasis, but a certain mortification of the stump. In cutting limbs huge 
chisels and mallets were used. At this period Botalli invented his guillotine, con- 
sisting of a sharp heavy axe, which, being allowed to fall from a height upon the 
limb, severed it instantaneously at a single blow. The revived or independent re- 
discovery of the ligature by Ambrose Par6 in 1579, and the discovery of the circu- 
lation of the blood by Harvey in 1628, led to the invention of Morel's tourniquet 
(1674), more commonly known as the Spanish windlass, and to the familiar instru- 
ment, Pettit’s tourniquet, which (introduced in 1718) perfected the means of securing 
prophylactic and direct haemostasis. From this time onward the treatment of the 
stump began to receive more systematic attention. Instead of merely chopping 
off a limb, the soft parts were detached from the bone, so that this could be sawn 
off at a higher level, in order to avoid the conical projection of the stump which 
invariably resulted when the primitive methods were adopted. All the methods 
of amputation that followed—and these were numerous—aimed chiefly at celerity, 
to reduce the pain of the operation to a minimum, hence the rapid circular section 
of the soft parts or the rapid transfixion methods which were so much popularized 
by the brilliant work of Liston, Lisfranc, Desault, Dupuytren, Langenbeck, and 
others. These finally yielded, in this modern period, to less rapid but more con- 
servative and perfected methods, which aim chiefly at the preservation of useful 
tissue and at securing the very best functional prosthetic stump for the patient. 
Such methods could only be perfected after the advent of anaesthesia and anti- 
sepsis. 596 
AMPUTATIONS. 
Classification.—All methods of amputation may be classified, 
according to the mode of division of the soft parts, into (1) the circular 
and its derivatives—the oblique, elliptical, oval, racket, and double-quad- 
rangular flap methods ; (2) the flap method ; and (3) the mixed, superficial 
flap of skin and deep circular of the muscles. 
The main point to be considered in the selection of a method 
is the following: the least sacrifice of the healthy tissue of the limb 
compatible with the saving of life and with the greatest possible use of 
the stump to the patient. 
To secure this most important desideratum the following conditions must be 
complied with: (1) The bone must be amply covered; (2) the skin must not be 
adherent to the bone nor exert pressure or traction upon the cicatrix; (3) the soft 
parts, especially the skin, must be subjected to the least traumatism compatible 
with the proper performance of the operation, with a view to disturbing the blood- 
supply and nutrition of the flap as little as possible; (4) the main vessels must be 
cut transversely; (5) the nerves must be cut high enough, so that they may not 
become adherent to the bone or cicatrix, or be affected by pressure upon atmo- 
spheric changes; (6) projecting angles or irregularities of the bone must be 
smoothed and rounded, so that they may not unduly press upon the soft parts; 
(7) the section of the soft parts must be made with the view of reducing the 
exposed scar-tissue to a minimum, and securing for this a position in the stump 
that shall be away from friction and the chief pressure-points in adjusting an arti- 
ficial limb or other prosthetic appliance. 
In connection with the last conditions perhaps it may be well to 
remember a few general facts of practical interest: The contractility of 
the skin is subject to great variations : it is practically lost in parts that 
have been long inflamed and oedematous. The average contractility of 
the skin may be represented by one-third of the length of any given 
portion. Thus a flap 12 cm. long will be reduced after section to 8 cm. 
The amount of retraction of muscles is proportioned to the length 
of the fibre; hence long-fibred muscles, like the sartorius, gracilis, 
the hamstrings, contract enormously. The contractility of all the 
soft parts together may be stated as follows: The primary and immedi- 
ate retraction of the tissues forming a flap may be represented as one- 
third of the length of the flap—that is, if a flap of 10 cm. is required 
to cover the bone, it should be cut 15 cm. (Farabeuf). In cutting the 
flaps we should therefore make allowance for this retraction, which is to 
be added to half the diameter of the limb in measuring the length of 
the flap. While half a diameter is usually given by most authorities as 
sufficient length of flap-covering, we believe that experience justifies the 
establishment of the general rule that the length of flap-covering for a 
stump, after making due allowance for primary or secondary retraction 
of the soft parts, should correspond to a full transverse diameter of the 
limb. In very wasted, relaxed subjects, with loose, pendulous skin, one- 
half a diameter will be amply sufficient. 
To meet the conditions of the present day some of the simplest and oldest 
methods, modified by the improvements of modern technique, have again been 
utilized, and are coming more constantly into surgical favor. These are the cir- 
cular incisions. With Kocher, Wyeth, and others we believe that circular ampu- 
tations fulfil the general indications better than any other fundamental type of 
operation. In circular amputations we include not only transverse incisions, but 
also those running obliquely to the axis of the limb, provided the line of the in- 
cision continues in one direction or the incision lies in a single plane. The addi- 
tion of a single longitudinal incision with rounding of the angles results in the so- PLATE XIII. 
Illustrating Lines of Skin Incision in Amputating at Various Levels. METHODS OF AMPUTATIONS. 
597 
called oval incision (an oval with a pointed side is not spdclly:an oval). The. 
addition of two longitudinal incisions with rounding of tlie arfgfik -results in a * 
true flap operation. , / 
The racket (Malgaigne’s en raquette) and the quadrangular flaJiS-otl.Iiavaton and 
Teale are transitions from the circular to the latter method. The tendency is, there- 
fore, to prefer the circular, modified to suit certain localities. We shall adopt it as 
a fundamental method of election, and shall refer to other procedures incidentally 
to the special amputations where they are indicated. ( Vide Plate XIII.) 
The transverse circular method is not only the simplest and the most 
easily executed, but it secures to the skin the best vascular supply and 
nutrition. It is contraindicated in favor of the oblique-circular or 
elliptical method, which is virtually also a single-flap method—(1) when 
more healthy skin is present on one side of the limb than on the other, 
otherwise the amputation would necessarily have to be carried higher; 
(2) when the cicatrix cannot be placed at the end of the stump, because 
it is exposed to pressure from below; (3) when, owing to the excessive 
elastic retraction of certain regions (as in the adductor and flexor 
regions of the thigh and the flexor region of the elbow), a transverse 
circular would leave an insufficient flap (Kocher). 
There are two modes of performing the circular amputation at the 
present day : (1) The simple (solid musculo-tegumentary) method, without 
cutaneous cuffs. 
Steps.—(1) Division of the Skin.—Both hands of the assistant retract the skin 
vigorously toward the root of the limb. With a medium-sized amputating knife 
the skin, subcutaneous adipose tissue, and superficial fascia are cut circularly 
with the same stroke. (2) At the margin of the fully retracted skin the muscles 
are divided in successive sections in a plane transverse to the axis of the limb. 
When the muscles are thick the superficial muscles are first severed and allowed 
to retract upward, and the deeper layers are divided in a higher plane because the 
superficial muscles usually retract more vigorously. When the periosteum is 
reached it is incised circulariy in the plane in which the deep muscles have 
retracted. The periosteum is pushed with an elevator along the bone as far as 
necessary to cover the sawed surface. The bone is severed at the margin of the 
detached periosteum. When the periosteum adheres closely, as on the rough lines 
of the epiphyses and tendinous attachments, it is separated with the knife. 
In all cases in which the end of the bone is to act as a direct support, and in 
the lower extremity where the soft parts are likely to rest against sharp projecting 
angles, these must be rounded off by the saw. 
This type of circular amputation can be advantageously modified by cutting a 
short cuff of skin (one-fourtli or one-fifth of the full length), after which the muscles 
are divided squarely to the bone and then elevated with the periosteum as before. 
(2) The Skin-cuff Circular (a la Manchette).—In this method the flap 
is made wholly of skin, which is dissected up to the line of bone sec- 
tion, where the muscles are divided perpendicularly to the bone. In 
making the dissection care must be taken to include the subcutaneous 
fat and superficial fascia in solido with the skin. The edge of the 
knife must never be directed toward the skin, but always against the 
underlying tissue. 
In order to facilitate the retraction of the soft parts, especially in well- 
developed muscular subjects, in cutting through conical regions, as in the upper 
third of the forearm, lower and middle third of the thigh, middle of the leg, and 
in disarticulating the shoulder and the hip, a liberating vertical incision, made in 
the least vascular and less exposed aspect of the limb, usually the outer surface, 
will aid very materially in facilitating the operation. In some regions two incis- 
ions may be required at equidistant points, which are cut straight to the bone 
parallel with the axis of the limb and at right angles to the circular incision, 
thus transforming the circular into two even equilateral musculo-cutaneous and 598 
AMPUTATIONS. 
well-nourished flaps, which are peeled solidly from the bone with or without the 
periosteum, as was suggested by Ravaton in the eighteenth century. 
A further modification of the solid circular which reduces the disturbance of 
the soft parts to a minimum is the method suggested recently by Neudorfer of 
Vienna (1891). In this procedure an incision is made on the outer or least vas- 
cular part of the limb parallel to the long axis of the bone. The knife is carried 
down to the point of the proposed osseous section. The bone is then divided with 
the chisel or a Gowan’s exsector, or, better, with a chain saw, and the soft parts are 
simply lifted up subperiosteally a sufficient length below the saw-line to ensure 
an ample covering. In certain conditions, such as amputations of the thigh for 
diabetic and senile gangrene, in which it is extremely necessary to protect the vas- 
cular supply from injury, this method is certain to remove the limb with the least 
exposure of the blood-vessels. 
The Elliptical method has already been referred to as an oblique cir- 
cular, and occupies an intermediate position between the circular and 
single flap. In this amputation the upper and lower ends of the 
ellipse are best marked by a small incision made by pinching up a 
fold of the skin and cutting over it. The skin and subcutaneous tis- 
sues are retracted by gliding or turning a cuff up to where the highest 
point of the ellipse is reached ; the muscles are cut squarely to the bone 
as in the circular incision. Guyon’s supramalleolar amputation of the 
leg, the elliptical disarticulation at the elbow, are examples of this 
modification of the circular. 
The Oval or Racket Method.—The incision takes the form of an 
oval with an end pointed (pedunculated oval) or of an isosceles triangle 
rounded at its base. The edges of the wound are united in its long axis. 
The most typical application of this method is seen in amputating the 
fingers. (See Fig. 259.) 
The Flap Method.—The flap may be either cutaneous or musculo- 
cutaneous. In every flap the skin must be cut larger than the muscles. 
Unless the flap is subperiosteallv dissected, a pure muscle-flap is unwieldy 
and difficult to adjust. A pure skin-flap is very apt to slough. This 
tendency, as Farabeuf has shown, is least observed in the integument 
about joints, where the vascular supply of the skin is derived from 
many channels. Flaps may be single or double. Carden’s original 
transcondyloid of the femur is a typical example of a single-flap method. 
The limb may be amputated by a long external flap method, but the 
oblique circular recommended in other places is almost identical in its 
technique and results. 
Double flaps may be antero-posterior or lateral. They may be equal 
in size or unequal. In order to meet the cylindrical form of the limb, 
the flaps will fit better if made of a U shape than if cut square. This 
can be done in a circular amputation with lateral incisions which have 
two even square flaps by rounding the corners (Ravaton, Langenbeck). 
The flaps may be cut in three ways: 
(1) By transfixion. This was the favorite method in the pre-anaes- 
thetic period, and in the hands of such masters as Liston, Lisfranc, 
Fergnsson, and others was marvellously rapid in its execution. 
The great objection to this method lies in the oblique and irregular division 
of the main vessels, which imperils the nutrition of the flaps, and also in the lack 
of control of the knife in making the section of the soft parts. The method can- 
not be recommended, and is rapidly becoming only historical. It is still applicable 
in cutting through tendinous regions, as in the wrist, after the circular section of 
the skin cuff from without inward. AMPUTATIONS OF THE UPPER EXTREMITY. 
599 
(2) By cutting a flap from without inward. The outline of the flaps 
is made by incising the skin with a scalpel. After the skin and fascia 
have retracted the muscles are cut obliquely to the bone, so as to leave 
a thinner section at the margin than at the base. Antero-posterior 
flaps of the thigh and of the arm may be cut artistically in this way 
by a skilled operator. Each flap should be at least half a diameter, 
and preferably three-fourths of the longest diameter of the limb. 
(3) Flap formed by enucleation or desossement. 
Subperiosteal excision is exhibited in its purest type in Teale’s 
double, unequal, quadrangular flap amputation, or in Stephen Smith’s 
hooded flap of the leg; also in lifting up from the radius and ulna the 
double square flaps resulting from a solid circular with two lateral 
incisions on the Ravaton plan.1 
SPECIAL AMPUTATIONS. 
A. Amputations op the Upper Extremity. 
Amputations of the Fingers.—Rules: (1) Save all parts of a finger, as 
no prosthetic appliance can replace the tactile or prehensile function of the lost 
digit. Exception : The proximal phalanges of the middle and fourth fingers, which 
usually remain stiff, extended, and in the way when the other fingers are present; 
save them, however, when all the other fingers are lost. 
(2) The palmar surface is the most exposed to friction; it is the most sensi- 
tive and useful; save and use it as flap material in preference to the dorsal integu- 
ment, so that the scar in the stump may be placed on the back of the hand, in the 
least sensitive and most protected locality. 
(3) The prominence of the knuckles is caused by the proximal bone (nearest 
the trunk), and the joint is below the knuckle. The line of articulation of the 
ungual and middle phalanx is one line, or one-twelfth of an inch, below the 
knuckle of the flexed finger; the joint of the middle and proximal phalanx is two 
lines, or one-sixth of an inch, below the knuckle; and the metacarpo-phalangeal 
joint is four lines, or one-third of an inch, below first knuckle (LeFort). This is 
important in disarticulating. 
(4) The joints are best exposed by flexing the finger. 
(5) The arteries and nerves exposed are situated on each side (lateral surface) 
of each finger—important for haemostasis and cocainization. 
(6) The synovial sacs which envelop the tendons of the thumb and little finger 
are prolongations of the common palmar bursa, which extends below the annular 
ligament into the forearm. The bursae of the other digits are independent of the 
palmar bursa. Hence the greater risk of palmar infection in amputations and 
injuries of the thumb and little finger. The tendon-canals of all the fingers 
directly lead to the palm: this is also an easy route for infection to the palm. 
Methods.—The method of election should be—(1) For disarticula- 
tion of phalanges: Lisfranc’s long palmar flap, made by running a long 
bistoury (finger-knife) into the joint and carrying it out between the 
distal phalanx and soft parts, until sufficient material is obtained to 
snugly cover the exposed proximal knuckle. This operation leaves a 
well-padded stump, without the scar in the dorsal surface. 
1 Teale?s Amputation.—Rule: Measure the circumference of limb on a level with 
future saw-line, cut a long flap, preferably on the exterior surface of the limb, measuring 
half a circumference in length and in breadth. Then a short (usually posterior) flap one- 
fourth the length of the long flap and one-half of the circumference of the limb in 
breadth. It is most applicable in the lower leg. 600 
AMPUTATIONS. 
(2) For amputation through a phalanx: (1) A short, dorsal square 
flap dissected directly from the bone; (2) a flap two-thirds longer taken 
from the palmar side is also lifted up from the bone, which is sawn or 
cut through with pliers. The flap is then turned over on the dorsum 
to be sutured to the short flap. This leaves an admirably well-padded 
stump. 
Amputation of the Entire Finger (inter-phalangeo-metacarpal dis- 
articulation).—The free edge of the web of the fingers, as measured from 
the palmar surface, is about three- 
fourths of an inch from the meta- 
carpo-phalangeal joint. The opera- 
tions of election for these fingers are 
—(1) for the index, a modified oval 
or racket flap, with longer flap pro- 
longation on the radial side, so that 
the scar will rest as far as possible 
from the exposed edge of the palm. 
A longer palmar flap will also ac- 
complish the same purpose. (2) For 
little finger (auricularis), the intero- 
external flap : the greatest length of 
the flap is on the ulnar side of the 
digit, so that the scar will be placed 
away from the ulnar or exposed 
aspect of the palm. (3) The middle 
finger is best removed like its fellow, 
the fourth finger, by either a simple 
circular cut corresponding to the line 
of the palmar web and a dorsal slit 
(Ravaton’s method), which allows a free exposure of the joint, or by a 
Malgaigne racket. (4) The thumb can be disarticulated with greatest 
advantage by either a single palmar flap or a Malgaigne’s racket. By 
whichever method, the sesamoids attached to the short flexor of the 
thumb should be resected. 
Amputation of Two or More Adjoining Fingers Simultaneously. 
—The best plan is to forego brilliancy and to adopt the incisions in each 
case which will ensure conservatism and scar protection. 
Fig. 259. 
Illustrating various finger amputations 
(Farabeuf). 
Amputation op Fingers with the Corresponding Metacarpals. 
General Principles.—(1) The amputation of a finger and a part of its 
metacarpal is a simple, benign, and conservative operation. 
(2) The amputation of a finger with a total extirpation of its metacarpal bone 
is a difficult, serious procedure which is rarely called for. 
(3) The only exceptions or partial exceptions are the first (thumb) and fifth 
metacarpal bones, the extirpation of which is comparatively easy and safe, owing 
to the partial isolation of their synovial articular bursse from the general carpal 
joint, with which they usually do not communicate. 
(4) The metacarpal bone should be enucleated without hacking the inter- 
osseous or palmar tissues and without wounding the deep palmar arch. It is 
impossible to avoid opening the great synovial sac of the carpus if the complete 
extirpation of the second and fourth metacarpals be undertaken. Hence the great 
attention to asepsis to avoid septic synovitis of the wrist. AMPUTATION OF THE HAND. 
601 
(5) The deep palmar arch crosses the shafts of the second, third, and fourth 
metacarpal bones close to their bases, and should be avoided. 
(6) Each digital artery bifurcates a little more than a quarter of an inch (in 
adults) above the free edge of the web of the finger. 
(7) The metacarpal bones are most accessible from the dorsal side. 
(8) The best method of amputating a finger with its corresponding metacarpal 
is by the racket method, Avith a long dorsal prolongation, Avhich extends on the 
dorsal surface from the phalangeo-metacarpal joint to the carpal junction. The 
palm should always be respected. The bone should be dissected only by enuclea- 
tion from the base of the finger toward the carpus, the soft parts be cleared by 
closely hugging the periosteum. By following these rules the only vessels requiring 
ligation will be the digital arteries at the Aveb. A disregard of this rule will lead to 
injury of the deep palmar arch and of the interossei, and to troublesome bleeding. 
(9) In extirpating the index and auricularis (little finger) incline the dorsal 
incision upAvard toAvard the ulnar side over the base of the metacarpal for the 
index, and toward the radial side for the little finger. The object of this is to 
place the sensitive scar as far as possible from the exposed margin of the palm. 
(See.Fig. 259.) 
(10) In disarticulating the thumb from the carpus remember the close prox- 
imity of the radial artery to the base of the first metacarpal: the artery dips into 
the palm in the first interosseous space. 
(11) In dividing the shaft of a metacarpal the best instrument is a scroll-saAV 
passed under the bone so as to cut upward. A Liston’s bone-forceps or metacarpal 
saAv may be used with less advantage, and the soft parts must be protected by 
a metallic spatula or a retractor passed under the bone. 
Amputation of the Hand—Radio-carpal Disarticulation. 
(1) The radio-carpal joint is crescentic in outline, the concavity directed 
toward the fingers. It is most superficial on the extensor surface. 
(2) The top of the styloid process is the best guide to the joint. 
(3) The skin on the dorsal surface is scant and lax, and retracts considerably 
when divided. Three centimetres should be allowed for this retraction (Farabeuf). 
(4) Pronation and supination will be affected by disarticulation of the radio- 
carpal joint, provided the radio-ulnar triangular cartilage be not injured and the 
small synovial bursa of the lower radio-ulnar joint be respected. 
(5) It is easy to mistake the intercarpal joint between the os magnum and semi- 
lunar for the true wrist-joint. This can be avoided by extreme flexion of the wrist 
and determining the position of the styloid process of the radius as a landmark. 
(6) The arteries that require ligation are the radial, the ulnar, and the anterior 
interosseous. 
(7) The stump resulting from a wrist amputation should be able to support an 
artificial hand, and should impart to the apparatus the rotary movements enjoyed 
by the radius. 
(8) So long as a stump has no scar upon its anterior or palmar surface, and 
especially none over the styloid process (the most exposed friction-point), it will 
allow of the adaptation of any prosthetic apparatus. 
Methods.—The ideal stump is best obtained by the elliptical or 
oblique circular, which is also practically a long palmar-flap method. 
The highest point of the ellipse is on the dorsum of the wrist, a little to 
the inner (ulnar) side of the middle line and half an inch below the 
line of the wrist-joint; the lowest point is in the palm on a line with 
the middle finger, and about the length of the diameter of the wrist 
from the highest point. In carrying the dorsal incision to the palm on 
the radial side the line should fall over the carpometacarpal joint of 
the thumb, well below the radial styloid. The outline of the ellipse 
Avith its palmar prolongation should be first cut with a scalpel from 
without inward, and the wrist subsequently disarticulated from within 
outward by cutting the extensor tendons, dorsal and lateral ligaments 602 
AMPUTATIONS. 
while the joint is flexed, and severing the deep flexor tendons close to 
the carpus as the knife leaves the joint. The stump will present the 
scar on the dorsum. (See Plate XIII., C and I).) 
Amputation of the Forearm. 
(1) The normal forearm is an elongated cone in shape, the base of the cone 
corresponding with the elbow; this makes it difficult to turn up the skin-cuff. 
(2) The lower third consists almost exclusively of tendinous masses covered 
with synovial sheaths, which are easily infected and may lead to rapidly ascend- 
ing purulent fusees of pus far from the line of section. The tendons are useless 
as flap material. 
(3) The skin on the flexor side retracts much more than that of the dorsum, 
in the upper third especially. 
(4) The arteries are normally the (1) radial, (2) ulnar, (3) anterior and (4) 
posterior interosseous, (5) comes nervi mediani. (In anomalous arterial conditions 
as many as eleven arteries have required ligation.) 
(5) The Esmarch constrictor must be applied above the elbow. 
Methods.—The best is the circular for the lower or tendinous third, 
and for the other parts, up to the elbow, two equal (autero-posterior) 
flaps, made by two lateral incisions, on the Ravaton plan. In the tower 
third a circular incision of the skin is made around the limb and dis- 
sected up with the fascia one diameter’s length from the cut edge of 
the skin to the future saw line. The cuff1 of skin is retracted and 
rolled over. On the level with the retracted skin-cuff the tendons are 
divided by cutting from without inward or by transfixing them from with- 
in outward (the latter procedure is the better). A three-tailed retractor 
is introduced after the interosseous space is cleared, and the naked bones 
divided with the saw, the radius first, as it is the movable bone. The 
limb should be held supine throughout the amputation, as this increases 
the size of the interosseous snace and maintains the bones on the same 
level. (See Plate XIII., C and D.) 
In the middle and upper thirds the circular is the best operation. 
At these points, where muscles are substituted for tendons, a very short 
skin-cuff is dissected upward, and the remainder of the soft parts are 
cut straight to the bone. The soft parts (muscles and skin) are then 
directly lifted from the bone, including the periosteum, for a distance 
of one transverse diameter from the cutaneous incision to the point of 
osseous section. If the limb be shrivelled, thin, and wasted, the soft 
parts can all be peeled up from the bone without difficulty. In well- 
shaped muscular limbs the retraction of the soft parts must be assisted 
by making one internal (ulnar) or two lateral incisions of sufficient 
length to permit their easy retraction from the bone and interosseous 
membrane. The retraction of the skin is always very great, so that 
Farabeuf believes that a full half circumference should be used for each 
flap. The stump that results from tins operation leaves a termino-lateral 
scar which is so well rounded, padded, and mobile that it never gives 
serious trouble in after life. 
Disarticulation of the Elbow. 
The exact position of the joint is determined by careful attention to the ana- 
tomical relations of the following osseous prominences: (1) The epicondyle or DISARTICULATION OF THE ELBOW. 
603 
external condyle of the humerus; (2) the epitrochlea or internal condyle of the 
humerus, more easily recognized in pathological conditions than the external; (3) 
the tip of the olecranon. 
The external condyle is situated three-fourths of an inch above the articular 
line; the internal condyle is more than one inch above. The humero-radial joint 
forms a straight line; the humero-ulnar, an inverted V, owing to the projection of 
the coronoid process, thus : When the forearm is extended the line of the joint 
is separated from the tip of the olecranon by two finger-breadths. The joint is most 
easily opened on the radial side, and should always be attacked by this route. 
The skin of the extensor surface is thin, and retracts but little; that of the 
flexor side is much more elastic and retracts remarkably, especially on the outer 
or supinator side. In making circular sections or flaps due allowance must be 
made for at least one-fourth retraction in the length of the flexor surface, and 
special provision made to protect the external condyle, which is most liable to 
exposure by retraction. 
The stump resulting from a disarticulation at the elbow is exposed to the 
greatest pressure and friction on the periphery and over the external condyle. 
The ideal stump should have the line of scar placed behind the humerus or at 
least within the olecranon fossa. The ideal is impossible to obtain, owing to the 
constant tendency of the flexor muscles to drag the scar forward, thus tending to 
leave a purely terminal scar, but yet a very useful stump. 
Methods of Election.—The circular operation, if made with a view 
to compensate for flexor retraction, must be obliquely inclined downward 
anteriorly, and thus virtually becomes an elliptical or single-flap ampu- 
tation. It is the simplest operation and yields the best stumps. The 
surest way to secure ample covering for the articular ends of the humerus 
is by cutting the lowest section of the ellipse the length of one trans- 
verse (transcondyloid) diameter. In an adult this is usually equal to 
one handsbreadth from the line of the joint to the point of section. 
1. The Anterior Oblique Circular or Elliptical.—The highest point 
of the ellipse is behind, over the prominence of the olecranon. The 
lowest point is on the anterior surface of the limb, a little above the 
middle of the forearm. (1) A cutaneous elliptical incision is begun 
over the olecranon and carried down to the anterior surface of the fore- 
arm. As the knife crosses the anterior aspect of the limb the forearm 
is kept extended, with the hand supine. The elbow is again bent as the 
knife is carried upward to the point of commencement over the olecra- 
non. (2) The anterior flap as mapped out by the incision is completely 
dissected up with the fascia until the level of the joint is reached, when 
the muscular layers are cut through to the joint. (3) The joint is opened 
on the radial side and disarticulated. (4) The triceps is divided. (5) 
After the ligation of the brachial the anterior long flap is turned back 
and sutured to the upper or posterior angle of the incision. 
(2) Posterior Oblique Circular.—(1) Determine the joint lines; (2) 
flex the forearm to an angle of 135°; (3) begin an oblique incision from 
the line of the joint, in form outward and backward, terminating poste- 
riorly a handsbreadth under the tip of the olecranon on the dorsal side. 
Complete the incision by carrying the knife up to the starting-point in 
front of the joint. When the forearm is flexed at the angle indicated 
the direction of the anterior incision is parallel to the prolonged axis of 
the arm. The dorsal flap with the periosteum, the attachments of the 
triceps and anconeus, are forced beyond the tips of the olecranon and 
the dorsal surface of the humerus. In front the soft parts with the 
joint capsule are divided transversely, the flesh being lifted and the 
knife carried into the humero-radial articulation. With the division of 604 
AMPUTATIONS. 
the tense internal ligament the operation is finished. Ligation of the 
brachial artery is made at the bend of elbow (Plate XIII., E and F). 
The Arm. 
(1) The arm is almost perfectly cylindrical in outline, hence most favorable for 
the circular method. (2) The retraction of the soft parts is notably greater on the 
flexor side. The important vessels lie on the inner side. 
Rule: Save all that you can up to the surgical neck of the humerus. 
Prophylactic haemostasis is secured by elevation of the limb and applying the 
elastic constrictor over the acromion, and holding it in position by the hand of an 
assistant when the upper third is involved. For the lower and middle thirds cir- 
cular constriction on a level with the lower border of the axilla is applicable here 
as usual. 
The classical methods of election are, for the lower third, the cir- 
cular, obliquely inclined downward, on the antero-internal surface, to 
compensate for flexor retraction ; for the middle, the antero-posterior flap 
method; for the upper third, a racket or oval, or the external-flap 
method of Farabeuf. 
The circular method, obliquely inclined to compensate for retraction, 
with an external liberating incision to facilitate the separation of the 
soft parts, as advocated by Wyeth, is the simplest, and yields perfectly 
satisfactory results at any level, and is here recommended in preference 
to all others. 
Steps.—(1) Make a circular incision through the skin fascia with a scalpel; dissect 
this up a short distance (one-fourth the length of the flap), and allow it to retract; 
(2) cut the muscles and all soft parts squarely to the bone; (3) elevate all the soft 
parts, including periosteum (except in children), up to the saw-line, which should 
be at a distance of one transverse diameter of the limb from the line of cutaneous 
section. 
The resulting stump will be a rounded, well-padded, mobile stump. The scar 
will be terminal and anterior, owing to the excessive retractile tendency of the 
flexor muscles. 
Disarticulation op the Shoulder. 
The scapulo-humeral joint is easily recognized and easily disarticulated. Its 
weakest and most exposed surfaces are on the anterior and external aspects of the 
shoulder. Prophylactic haemostasis is a primary consideration. The important 
axillary vessels and nerves lie on the inner or axillary aspect of the joint. To 
control the axillary artery several procedures have been recommended: (1) Digital 
or mechanical compression of the subclavian in the supraclavicular fossa; (2) pre- 
liminary ligation of the axillary; (3) primary disarticulation of the humeral head 
without severing the internal axillary flap (which contains the nerves) until this 
has been grasped and compressed by the fingers of an assistant. All these are 
unreliable, and have yielded to two haemostatic procedures which control the 
bleeding in all cases: Whenever the shaft of the humerus is intact or is pre- 
served up to the deltoid insertion, the elastic constrictor is applied over the 
shoulder and vertically across the axilla, and, securely clamped or fastened over 
the acromial end of the clavicle, will entirely control the axillary vessels, provided 
these are ligated at the point of humeral section before the disarticulation is effected. 
Of the thirty -six methods mentioned by Lisfrane and twenty-eight 
figured in Farabeuf’s Atlas, only one will be considered, as it is the 
simplest, most satisfactory, and generally applicable. This is the circular 
with a vertical anterior or external incision. In its result this is essen- 
tially equivalent to Spence’s anterior and Larrey’s external “ racket ” DISARTICULATION OF TIIE SHOULDER. 
605 
methods. The difference lies simply in the fact that the angles of the 
modified circular are rounded in the racket (Plate XIII., F). 
The Modified Circular.—Steps.—(1) Elevate and milk the limb to 
drain out the blood, or apply the Esmarch bandage; (2) apply an elastic 
constrictor across the axilla, and secure it by tying or by a clamp above 
the shoulder; (3) make a horizontal circular incision on a plane a little 
below the anterior axillary border ; (4) dissect the skin a short distance 
and allow it to retract; (5) with the arm held in adduction cut all the 
soft parts to the bone; (6) dissect the soft parts in solido from the bone, 
especially on the axillary aspect; and (7) find the axillary artery and 
vein, which must be ligated on a level with the transverse line of section : 
Fig. 260. 
Esmarch’s strap applied in high amputation of the arm (Smith). 
this will protect the patient from all dangerous hemorrhage; (8) make 
a vertical incision extending from the anterior border of the acromion 
externally to coronoid process and a little external to pectoro-deltoid 
groove, cutting closely to the bone until a junction with the horizontal 
circle is effected ; (9) dissect up the solid musculo-cutaneous flaps in 
each side of the vertical incision, thus completely enucleating the bone 
and exposing the joint; (10) disarticulate by opening capsular ligament 
and detaching the scapulo-humeral group of tendons. 
No vessels of importance, except possibly a circumflex branch, will now require 
ligation, even if the constrictor should slip when disarticulated. 
The principle involved in this procedure is essentially that of Fourneaux 
Jordan’s disarticulation of the hip—i. e. to enucleate and disarticulate the humerus 
after securing the vessels at their peripheral section, while these can be controlled 
by the constrictor.1 
Wyeth’s Method.—When after excision of the humeral head an 
amputation becomes necessary, or when the limb has been torn away so 
that an insufficient support is given to the elastic constrictor, and this 
is likely to slip over the stump after disarticulation, it will be safer to 
introduce a large mattress needle through the anterior axillary fold and 
another through the posterior fold, on the plan advocated by Wyeth in 
disarticulating the hip, for the purpose of preventing the elastic band 
from slipping over the stump before the vessels can be securely ligated. 
1 The method is identical with that originally suggested by Eavaton for disarticula- 
ting the hip; Jordan simply modernized the procedure. As described above, it is the 
operation practised by Esmarch and others. 606 
Amputation op the Entire Upper Extremity, including Parts 
of the Clavicle and the Whole Scapula (Interscapulo- 
thoracic Amputation). 
AMPUTATIONS. 
In the typical operation the whole limb is removed with the scapula 
and outer two-thirds of the clavicle. The external incisions have been 
materially modified by Chalot, Kocher, and others. Only the Berger- 
Farabeuf operation will be here considered. 
Steps.—(1) The clavicle is exposed, and is divided at the juncture 
of the middle with the inner thirds. The middle third is excised. The 
subclavian vessels are exposed and secured by a double ligature and 
divided. (2) An antero-inferior flap is cut, which, beginning at the 
point of clavicular section, is carried in a curve downward and outward 
along the outer edge of the delto-pcctoral groove, under the axilla to 
the edge of the posterior axillary fold. (3) A postero-superior flap is 
fashioned by continuing the axillary incision previously described down- 
ward and inward, to stop over the posterior surface of the inferior angle 
of the scapula. In the last part of its course the knife follows the 
groove between the vertebral border of the scapula, and cuts through 
the muscular mass formed by the teres major, latissimus dorsi, etc. 
(4) After cutting through all the soft parts and securing the supra- 
scapular arteries the extremity is removed by dividing the tissues still 
connecting the scapula to the trunk. 
B. Amputations op the Lower Extremity. 
The Foot.—General Considerations.—The operator must always bear in mind 
that the foot is essentially— 
(1) An organ of sustentation or support and of locomotion; 
(2) A tactile organ ; 
(3) And, exceptionally, a prehensile organ. 
The two last functions are not essential to easy locomotion, and can he dis- 
pensed with in the ordinary occupations of civilized man. The hand, per contra, 
is essentially a prehensile and tactile organ capable of the most highly differenti- 
ated mechanical functions. No artificial appliance can be efficiently substituted 
for an amputated hand. It is easy to replace an amputated foot only by an efficient 
artificial substitute, provided a perfectly healthy and painless stump is left after an 
amputation. No partial or complete amputation of the foot can be made physio- 
logically useful to the bearer unless it complies with the following conditions: 
(1) It must be provided with a perfectly sound pressure-bearing plantar sur- 
face, which can bear the body’s weight and resist the constant friction of standing 
and walking in active life without undergoing pathological changes—viz. ulcera- 
tion and neuralgia. 
(2) This result can only be obtained by adopting sucb a method of amputation 
as will give (a) an ample covering to the bones bearing the body pressure; (b) that 
will solely utilize plantar flaps, which are alone capable of bearing the body 
weight; (c) that will place all scar-tissue in the most protected locality—i. e. the 
dorsum of the foot. These conditions must be complied with or the foot-stump will 
be useless as a base of support and will be a source of perpetual distress to the bearer. 
Hence the extreme conservatism advocated in dealing with the upper extremity 
can be disregarded in the foot whenever the injury or disease will not permit the 
surgeon to comply with these essential conditions. Every other condition must 
subordinate to the one essential requisite—i. e. to leave a useful walking stump. 
Hence the key to success in all methods of amputation of the foot will be found in 
the ruling principle—a sufficiency of plantar flap to permit the cicatrix to be 
placed on the dorsum of the foot. AMPUTATIONS OF THE LOWER EXTREMITY. 
607 
Amputations of the toes are almost always disarticulations, owing to 
the shortness of the phalanges. Every care must be taken to save as much 
of the metatarsus, and especially of the first metatarsal and phalanges 
of the great toe, as possible. The same care need not be taken to pre- 
serve every possible part of the four outer toes. “ A sloughing stump 
has often resulted from trying to preserve these almost useless digits.” 
(1) Interphalangeal disarticulations are best effected by cutting a 
long plantar flap (Lisfrane’s), which will leave the line of scar on the 
dorsum. 
(2) Metatarso-phalangeal disarticulations are made by the oval 
method. 
Method of Election for the Big- Toe.—By internal plantar or oval 
flaps prolonged on the mesial side to thoroughly protect the metatarsal 
head. Leave the cicatrix in the interosseous space (Plate XIII., G). 
Disarticulation of the little toe at the metatarso-phalangeal joint. 
The same principles apply in this toe, modified to protect the exposed 
outer side. 
Disarticulation of all the Toes at the Metatarso-phalangeal 
Joint.—A continuous dorsal incision and complete musculo-cutaneous 
flap on a level with the interdigital web. On the inner and outer border 
the incision is shaped so as to cover efficiently the heads of metacarpals. 
The cicatrix must lie entirely on the dorsum. 
Amputation of a Toe with its Corresponding Metatarsal.—A 
racket incision, a prolongation that reaches the corresponding tarsal 
(cuneiform) joint. In each case enucleate the metatarsal subperiosteally 
through a purely dorsal incision. Remove only the bone; level all the 
soft parts behind. In the case of the first and fifth metatarsal bone 
incline the racket so that the scar will be mesially inclined and removed 
from the edge of the foot (Plate XIII., G). 
Partial Tarsal Amputation of the Foot.—A great many typical oper- 
ations have been described by operators for the partial amputation of the 
foot at the metatarso-tarsal, medio-tarsal, and other joints, all based upon 
the fundamental idea that the foot is composed of many bones which are 
held together by numerous complicated joints that must be respected by 
the surgeon. While this idea is entirely correct from the anatomist’s 
point of view, it should be entirely disregarded by the surgeon whenever 
the exigencies of conservative surgery demand it. There is no special 
advantage in following articular lines. It is hard to break through 
surgical traditions that have been handed down from generation to gen- 
eration, but it is nevertheless wrong to sacrifice even a quarter inch of 
foot-tissue for the mere sake of following a classical procedure. As 
Agnew taught long ago in this country and others elsewhere (Guerin, 
Mayer, Koclier), the skeleton of the foot must be considered a surgical 
unity to be treated by the knife and saw, just as the femur or humerus 
would be, at the exact point which will yield the longest and most use- 
ful stump to the patient. What is essential in every case is the applica- 
tion of the principle of plantar flaps—preservation and scar-protection. 
Some surgeons and artificial-limb manufacturers have lately boldly 
urged the complete abandonment of all tarsal and tibio-tarsal opera- 
tions. Truax, whose large experience as a mechanic entitles his views 
to special consideration, has thus formulated his opinion: “ Avoid 608 
AMPUTATIONS. 
amputation within three inches of the ankle-joint. Do not amputate 
between the metatarsal bones and the junction of the lower and middle 
thirds of the tibia. At all other points save all you can, and you will 
in every case have done the best for your patient.” This would exclude 
all conservative foot operations, from Lisfranc’s joint (tarso-metatarsal) 
up to the point of election in the leg. 
The reasons given for this extreme view are that all these tarsal operations 
sever the flexor and extensor tendons of the foot and cut through its arch, thus 
destroying its elasticity as well as nearly all its power of flexion; that the foot is 
so shortened that when in an active state at the time when the limb is inclined 
obliquely backward, it cannot be used as a lower or main propelling power by 
which the body is advanced to a position perpendicularly over the forward limbs. 
This is important, for the loss of a portion of the foot in most cases necessitates 
the taking of a shorter step and a greater flexing of the knee of the said limb. 
This raising of the body with every step requires additional labor and causes the 
limp so noticeable in this class of cases. 
It is also argued that it is much more difficult to adjust a well-fitting artificial 
limb to a partially amputated foot than it is to the leg-stump after amputation at 
the point of election, and that, finally, a well-made artificial foot, with its perfect 
mechanical ankle, is free from all the objectionable features of the partially am- 
putated foot. With the artificial foot the patient does not limp, and he walks so 
perfectly that it is impossible to discover by mere inspection that he wears an 
artificial substitute for the lost limb. Other prosthetic mechanics, on the other 
hand, contend that the mechanical difficulties in the way of adjusting proper arti- 
ficial substitutes for partially amputated feet are not insurmountable, and, in fact, 
are readily overcome, so that a patient with a partially amputated foot can be 
made to walk as gracefully as well as when the original natural limb existed. 
Granting the contention that partially medio-tarsal stumps are more difficult 
to treat prosthetically than sound leg-stumps, and that it is true that an artificial 
foot can be made to walk more elegantly and naturally than a partially amputated 
foot without prosthetic compensation, we must still remember that hundreds of 
men walk painlessly and comfortably upon medio-tarsal stumps without the help 
of any artificial substitute, and that if they do limp, they are nevertheless not 
abjectly dependent on an artificial limb, which is costly and must be renovated at 
intervals. With the poor and dependent, who find it practically impossible to 
economize, this- is a matter of serious consideration. 
We would therefore formulate the following rule : 
Amputate the foot conservatively—save all you can whenever a suf- 
ficiently long healthy plantar or heel flap can be obtained. If the proper 
flap material be wanting and scar-tissue must remain on the exposed 
plantar surface, amputation above the malleoli or at the prosthetic point 
of election in the leg (junction of lower and middle thirds) of tibia. 
Medio-tarsal or intramalleolar stumps, if properly made, if painless and 
healthy, will be equally useful to the poor and the wealthy—to the poor 
man, because he will be able to walk independently of an expensive 
artificial limb; to the rich man, because he will be able to adopt a com- 
pensating appliance that will disguise his deformity. 
In all of the partial amputations of the foot a long plantar and a 
short dorsal flap—cut from without inward—should be made before 
sawing or disarticulating the soft parts. 
Through the Metatarsus.—By sawing transversely at any level up 
to the tarso-metatarsal or Lisfranc’s joint (Plate XIII., H). 
Typical Tarso-metatarsal Disarticulation—(Lisfranc’s, 1818).— 
The anterior part of the foot is removed; the seven tarsal bones are 
left in the stump. The plantar flap extends to the middle of the balls 
of the toes. The joint line is indicated laterally by the tuberosity of AMPUTATIONS OF THE LOWER EXTREMITY. 
609 
the fifth metatarsal, behind which lies the line of the joint. On the 
inner side a small eminence, the base of the first metatarsal, is dis- 
tinctly palpable. The line of the joint is convex downward and out- 
ward, and has a depression above, due to the recession of the second 
cuneiform bone, which lies back of the general articular line 2 to 3 cm. 
The strongest ligament is between the first cuneiform and base of the 
Fig. 261. 
Fig. 262. 
Tarso-metatarsal disarticulation (Farabeuf) 
second metatarsal (Lisfranc’s ligament), and until this is severed (the 
master-stroke) the joint cannot be made to gape. As in all operations 
of the foot, the vessels are preserved in the plantar flap, great care 
being taken not to injure them, on a level with the divided bone. 
Lisfranc’s operation is an admirable exercise on the cadaver, but 
it is rapidly becoming historical in practice, an even and simple saw 
section being substituted with advantage for the more difficult disar- 
ticulation. 
Modifications are numerous; the best known are simply mentioned 
for convenient reference. 
Stump after same. 
Hey's (1799).—Disarticulated on the metatarso-tarsal joint, as in a typical 
Lisfranc, up to the first metatarso-cuneiform joint, when the projecting end of the 
first cuneiform was sawn through and excluded from the stump with the corre- 
sponding metatarsal bone. 
Bauden's.—The first metatarso-cuneiform joint is disarticulated, and the saw is 
carried transversely through the bases of the four remaining metatarsals. 
S. Key's.—The whole tarso-metatarsal joint is disarticulated except the second 
metatarsal, the base of which is sawn through on a level with the first metatarso- 
cuneiform joint, and allowed to remain in its mortise. 
Medio-tarsal Disarticulation.—(Chopart’s Operation, 1787).—In 
the typical operation the astragalus is disarticulated from the scaphoid, 
and the calcaneum from the cuboid. The astragalus and calcaneum are 
the only two bones left in the stump (Plate XIII., H). 
The line of the joint is indicated on the inner side by the marked 
projection of the tuberosity of the scaphoid bone, behind which it lies, 
and on the outer side by a tubercle on the body of the calcaneum, 
which lies just behind the calcaneo-cuboid joint. An oblique circular 610 
AMPUTATIONS. 
or elliptical incision strikes the line of the joint on the dorsal aspect, 
and passes behind the balls of the toes on the plantar surface. Two 
short dorso-lateral incisions facilitate the exarticulation (Kocher). 
The main connection between the bones is the Y-shaped ligament 
from the body of the calcaneum to the scaphoid and cuboid. 
The operation has often resulted in a bad stump, owing to equinus position of 
the foot and chafing at the anterior and inferior angle of stump, especially when 
the scar is left too low anteriorly. The best preventive measure for this is to 
attach the dorsal extensor tendons firmly to the stump, prophylactic tenotomy of 
the Achilles tendon, and primary union to reduce to a minimum the amount of 
scar-tissue. 
As in Lisfranc’s operation, the saw can be carried through the line of the joint 
without regard to the articular lines, any loose or thin shavings of bone or carti- 
lage that may remain being removed after the section. The astragalus may be cut 
through with saw 1 cm. behind Chopart’s astragalo-scaphoid joint, without impli- 
cating the ankle, thus ensuring still a movable stump. 
Modification.—(1) Albert of Vienna endeavors to counteract the 
retractile tendency of the Achilles tendon by a special procedure. He 
cuts the tendons of the common extensor of the toes tAvo inches belotv 
the line of the dorsal flaps. The joint between the scaphoid and cunei- 
form is opened, the cuboid being sawn through as in Forbes’ amputa- 
tion. Two holes are bored—one through the scaphoid, and the other 
through the cuboid. The extensor tendons are passed through these 
perforations and sutured to the plantar fascia. In this way the exten- 
sors retain a firm control of the plantar end of the stump and the mus- 
cular equilibrium is maintained. 
(2) Forbes and Bona saw through the cuboid and disarticulate the 
scaphoid from the three cuneiforms, thus leaving three and a half bones 
in the stump. 
(3) Jobert disarticulates the scaphoid from the cuneiforms, and the 
cuboid from the three last metatarsals. 
(4) Laborie separates the scaphoid from the three cuneiforms, and 
the cuboid from the calcaneum.1 
Subastrag-aloid disarticulation consists in disarticulating the astrag- 
alus from the calcaneum and cuboid. It leaves only one bone of the 
foot in the stump. 
The original operations proposed by Lignerolles (1839) and Textor (1841), 
subsequently popularized by Malgaigne, and the numerous modifications that 
have followed, can be resolved into two methods of cutting the soft parts: (a) The 
oval or racket; and (b) the heel-flap method. The oval incision begins horizontally 
under the tip of the external malleolus, extending toward dorsum to Chopart’s 
line (which is distinctly marked, as above, by the tuberosity of the scaphoid), 
along which it descends vertically to the sole on the internal side, back to the 
point of beginning on the outer side. Chopart’s joint is opened from above 
between the head of the astragalus and the scaphoid. Then, without penetrating 
deeper into this joint, the narrow knife is turned immediately upward and back- 
ward under the head of the astragalus, so as to sever the strong interosseous 
astragalo-calcanean ligament in the sinus tarsi, and the calcaneum is enucleated 
close to the periosteum in the upper, outer, and lower surface, then inward, and 
lastly posteriorly. On the inner side the most difficult step is the separation of 
the sustentaculum tali, which extends high up. When the skin-covering is insuf- 
ficient the head of the astragalus is sawed off (Kocher). 
1 Other modifications could be multiplied, but these are amply sufficient to empha- 
size the great utility of the doctrine of the unity of the foot, which teaches that we must 
disregard articular lines, and thus simplify the practice of conservatism. AMPUTATIONS OF THE LOWER EXTREMITY. 
611 
Modification.—(a) Baudens (1848) sawed the inferior surface of the astragalus 
in a horizontal plane to create a flat resting surface. 
(b) Hancock (1864), after a horizontal section of the astragalus, sawed through 
the calcaneum and attached the remaining portion of the bone to the astragalus 
on the Pirogoff plan. 
(c) Roux and Blasius cut vertically through the head of the astragalus and 
anterior portion of the calcaneum without disturbing the joint between them. 
(d) Tripier sawed the calcaneum horizontally just below the articulation of this 
bone with the astralagus. The joint is respected, and a thin horizontal section of 
the os calcis remains attached (articulated) to the astragalus. 
Perrin, Verneuil, Farabeuf, and others have modified the cutaneous incisions 
in various ways with the view of utilizing the soft parts to the best advantage, but 
the essential principles are the same in all—viz. to attack the joint always on the 
outside—to be extremely careful not to injure the vascular (nutrient) internal flap 
and the necessary heel surface, so that a healthy, resisting, walking surface may 
be preserved. A failure to comply with these conditions means a worthless stump 
and a secondary amputation. 
Tibio-tarsal Amputation.—Total amputation of the foot (Syme’s 
operation). In the original operation the whole skeleton of the foot is 
removed, including the ankle-joint with the malleoli. The cutaneous 
hood of the heel, which contains the calcaneum, alone remains as a flap 
with which to cover the sawn surfaces of the tibia and fibula. This is 
still a very useful operation (Plate XIII., H). 
(1) The foot is held flexed at right angles with the leg. A deep 
incision is made, penetrating to the bone throughout its course from the 
apex of one malleolus to the other, crossing the sole of the foot trans- 
versely. (2) The foot is lowered, pressed strongly downward, and a 
second incision made transversely across the anterior surface of the 
ankle-joint from the apex of one malleolus to the other, joining the ver- 
tical with the horizontal incision. (3) Open the ankle anteriorly; cir- 
cumscribe the malleoli; divide the lateral ligaments; dislocate the 
astragalus forward. (4) The os calcis is now exposed by traction, and 
the heel-cap is carefully peeled away with the knife from the calcaneum, 
being extremely careful not to buttonhole it. The heel-cap can be dis- 
sected or peeled off' first before opening the ankle. (5) Retract the heel 
and all soft parts away from the tibia and malleoli, and run a saw 
transversely just above the articular line of the tibia, thus removing 
the malleoli. The cartilaginous surface may be left behind, and the 
malleoli alone removed. (6) The hood of the flap is now raised and 
sutured over the divided tibia to the anterior skin of the leg. If 
drainage be required, tap the heel-cap on the outer side of the tendo- 
Achilles attachment; never perforate the plantar or active surface of 
the stump. 
Special Recommendation.—Never cut obliquely backward on the inner 
border of the heel-flap, or encroach upon this beyond the vertical line 
indicated, for fear of mortification through injury to the posterior tibial 
and plantar vessels (Wyeth). 
Pirog-off’s Modification.—The leg-bones are sawed off* by a Syme’s 
operation just above the articular line, and to the sawed surface is 
attached a posterior section of the tuberosity of the calcaneum. The 
preservation of this part of the os calcis has the great advantage that 
the skin of the heel remains well nourished and the so-called heel-cap 
remains filled. With Kocher, Wyeth believes it preferable to Syme’s 
disarticulation as a walking stump. 612 
AMPUTATIONS. 
Modifications.—Roux and others have modified Syme’s operation by an oval 
incision which utilizes the internal and plantar surfaces of the foot, so that the 
cup of the heel is divided, and still a walking plantar surface is retained. The 
incisions are very much as in subastragaloid by oval section. 
Pirogoff’s operation has been modified by making a horizontal section of the os 
calcis instead of the vertical division in the original operation (Pasquier and 
LeFort), or by making a curved section of the calcaneum, to be adjusted to a con- 
vex section of the tibia and fibula (Y. Bruns), or by cutting the os calcis obliquely 
to fit an oblique section of the tibia (Gunther). The original simple vertical sec- 
tion is the simplest and most readily executed. Tauber, Chaput, and others saw 
the os calcis vertically in two halves, and turn up the internal sawed surface and 
attach it to the horizontal section of the bones of the leg. 
These modifications are all intended to favor the closer approximation of the 
sawed calcaneum to the leg-bones, but they are of doubtful utility. 
Other atypical conservative operations on the foot have also 
been devised to meet certain unusual pathological or traumatic con- 
ditions (Plate XIII., I). 
Anterior osteoplastic tarsectomy, leaving the plantar surface untouched, 
but shortening the foot (Link’s operation, 1887). (See Fig. 263.) This 
Fig. 263. 
Fig. 264. 
Link’s osteoplastic substitute for Chopart’s amputa- 
tion (Chalot). 
Same, showing result. 
is indicated wherever the dorsum of the foot is injured or diseased and 
other parts are sound. 
Posterior osteoplastic tarsectomy has been already described (p. 645, 
Yol. I.). 
Amputation op the Leg. 
In olden times, when the injury or disease was below the knee it was custom- 
ary to amputate at the upper third of the leg, with the view to flexing the knee- 
joint and resting the body on the knee on the generally used peg leg. If the injury 
were at or near the knee, then, when possible, at the lower third of the femur, as 
giving the best stump or one most easily fitted to a conical socket, and which 
would support the necessary pressure on the sides of the stump in walking. In 
these days, however, the peg leg is rarely seen except among the extremely poor 
class (the indigent negro population of the South most often), and the mutilation 
is not so palpably advertised. With the great advances accomplished in the last 
few years in the manufacture of artificial limbs, and the great reduction in their 
cost which has made them attainable by almost all classes, the old points of elec- 
tion have radically changed and the technique of amputations, especially of the 
lower extremity, lias been more than ever subordinated to the exigencies of the 
prosthetic art. AMPUTATION OF THE LEG. 
613 
It should be remembered that in amputations through the continuity 
of the leg the weight of the body is borne by cone-shaped sockets which 
hold the stump very much as if we attempted to lift a person from the 
floor by grasping the leg below the calf with both hands. The pressure 
is therefore circumferential, and in the leg the greatest friction- and 
pressure-point is in the antero-inferior surface of the stump, which is 
chiefly used in lifting the artificial leg in walking. 
Diametrically opposed to the old teaching, we now understand that 
we cannot have too much natural leg. It is the lever that controls the 
artificial part, and the longer the lever the better the walking results. 
While the majority of skilled mechanics agree that it is possible to fit an artifi- 
cial limb to any length of leg, it is admitted there are some bone-sections that are 
much more desirable than others from the purely prosthetic or mechanical point 
of view. Thus, instead of considering the point of election to be a handsbreadth 
below the knee-joint, as it used to be, the ideal point of election is now placed at the 
junction of the middle and lower thirds of the tibia—the point of election, be it under- 
stood, only referring to the bone, and not the soft parts. This leaves space enough 
underneath the end of the stump for the placing of an artificial joint of the most 
approved pattern, giving a stump of ample length to provide sufficient leverage to 
enable the patient to easily swing a substitute, besides leaving the calf in a cone 
shape, that it may be made to assist the head of the tibia in supporting and carry- 
ing the weight of the body. 
The tibia of an adult should not be amputated at a point less than two 
and a half or three inches from its upper articular surface, as it will flex 
under the influence of the stronger flexors. The knee will be useless as 
an articulation, but it will make an excellent stump, as it gives the best 
possible support. 
Bearing in mind that the most active surface of the stump left after 
a leg amputation is its antero-inferior angle, the greatest care should be 
observed in securing a stump that will exclude most rigorously all sensi- 
tive and weak scar-tissues at this point. Hence all operations must be 
rejected which systematically throw the cicatrix in front of the shin. 
The methods which are best calculated to meet the essential condition— 
the line of scar posteriorly placed—are : (1) The modified circular (also 
called bilateral) flap of Stephen Smith; (2) Bruns’ circular [oblique), 
with lateral liberating incisions which convert the stump into an equal 
(quadrangular) antero-posterior flap operation; (3) the long anterior and 
short posterior flaps, curved or quadrangular (Teale’s); (4) the long antero- 
external; (5) the simple long anterior flap (Bell). 
The only exception to the general rule is in the supramalleolar amputations, 
where Guyon’s very elliptical flap, borrowed from the heel, can be turned forward, 
so that the thick heel-skin lies in front and under the tibia, where it is capable of 
sustaining considerable pressure. 
Any of these methods will yield admirable stumps, provided the following con- 
ditions are complied with : (1) That there shall be an ample sufficiency of well- 
nourished flaps; (2) that the projecting antero-inferior angle of the tibial crest be 
rounded off; (3) that the fibula be cut at a higher level than the tibia, so as to 
favor a conical formation of the stump; (4) that the scar-tissue be kept away from 
the antero-inferior angle or surface; (5) that the end of the stump be mobile and 
not adherent to the bone (which is best obtained by retaining solid musculo-cuta- 
neous flaps and periosteal cuffs); (6) that the nerve-trunks be cut high up above 
the peripheral line of pressure. 
At the Supramalleolar Point—Guy on’s Amputation (see Fig. 
265)—Make an elliptical cutaneous incision which crosses the heel below 614 
AMPUTATIONS. 
the tendo-Achilles attachment, and reaches a point one inch above the 
lower articular edge of the tibia anteriorly. Dissect up a solid flap pos- 
teriorly from the heel, cutting through the tendo-Achilles at its inser- 
tion, hugging the bone all the way. Divide the anterior extensor ten- 
Fig. 265. 
Guyon’s supramalleolar amputation (Farabeuf). 
dons transversely—by transfixion preferably—and saw the bones above 
the malleoli, so that the lower or heel end of the ellipse may be brought 
distinctly forward. Be careful to cut the post-tibial nerves high up, so 
that they shall not be exposed to pressure. 
At the Point of Election (junction of middle and lower thirds of 
tibia) (Plate XIII., I.).—Commence an incision with a large scalpel in 
the centre of the anterior surface, and carry it downward along the side 
of the leg, so as to make a slightly curved flap with its convexity 
below: when the incision passes over the prominent part of the leg 
toward the posterior surface, incline it upward until the middle of the 
limb is reached, where it should be continued directly up (on the racket 
plan) to the point at which the bone is to be divided ; make a similar 
incision on the opposite side. Dissect the skin up to the extent of one 
inch in the adult leg (two inches in the thigh). Now make a circular 
division of the muscles to the bone with a long knife. Saw the bone at 
this point, and direct an assistant to seize and hold the extremity firmly 
with strong bone-forceps. With the elevator raise the periosteum from 
the tibia to the point where the latter is to be cut; divide the bone again 
at the base of the periosteal flap (half a transverse diameter of leg from 
edge of retracted flap to the last saw-line). The fibula must be cut at a 
higher point. The Gowan-Wyeth exsector is advantageously used here : 
a narrow metacarpal saw, or even a chain-saw, will effect the division of 
the fibula with little injury to the soft parts. 
The stump left by this amputation is covered by the integument internally, 
the periosteum externally (in young children the periosteal cuff is not desirable, as 
the bone is reproduced too rapidly and a pathological conicity of stump will 
result), while the intervening tissues—muscles, vessels, and nerves—have not been 
disturbed in the dissection. The periosteal flap falls like a hood over the end of AMPUTATION OF THE LEG. 
615 
the bone; the skin-flaps lie in contact without tension ; the drainage is direct from 
the angle behind. When cicatrization is complete the cicatrix lies posteriorly to 
the end of the stump; the terminal cushion is freely movable, and the bone does 
not undergo the usual amount of atrophy. 
This method is described in detail, owing to the importance of the correct prin- 
ciples of flap-formation that it illustrates in this most important region. This 
method of amputating is much more tedious than the old rapid circular with cuff 
or flaps, and is therefore not very popular with the rapid amphitheatre teachers of 
the old school, but the admirable stump that results from it amply compensates for 
the time taken in its execution. 
In this, as in other solid flap or periosteal operations, the metallic retractor 
shields of McCurdy will be found to be of some service in protecting and retract- 
ing the soft parts. 
Bruns’ Method.—Draw the skin up strongly and make an oblique 
circular incision down to the bone at a distance below the future saw- 
line equal to two-thirds of the diameter of the leg at the saw-line. 
Liberating incisions, about two inches for adults, are carried upward 
from the circular incision, dividing all the soft parts over the inner 
border of the tibia and the outer aspect of the fibula. Without dis- 
turbing the attachments of the skin and underlying soft parts, the 
Fig. 266. 
Fig. 267. 
Keetley’s dermatoplastic amputation of foot, necessitated by extensive ulcer (Chalot) 
periosteum is carefully raised from the tibia and fibula as high as the 
lateral liberating incisions extend, and first the fibula and then the tibia 
are sawn through. The tibia, as in other operations, is cut obliquely to 
prevent angular projection of the crest. This amounts to a subperiosteal 
excision of the bones of the leg, and leaves an exceedingly serviceable 
and well-protected stump. The angles of the flaps can be rounded olf 
if preferred. When finished this leaves a double antero-posterior flap 
stump. 
Atypical Methods.—In conditions which admit of supramalleolar amputations 
in the poor class it is desirable to obtain, if possible, a pressure-bearing stump 
upon which the patient can walk without the necessity of wearing expensive 616 
AMPUTATIONS. 
apparatus. When a good heel-flap can be obtained Guyon’s method (Fig. 265) will 
be all-sufficient. Nevertheless, Bier of Kiel has attempted to solve the problem by 
chiselling a piece of the tibia and placing it horizontally against the remaining 
end of the bone, so as to form a kind of artificial foot. This shortens the leg too 
much, and is hence worthless. Kummer of Geneva proposes to preserve a long 
posterior heel-flap which remains attached to the leg, but not attached to the bone, 
until a perfectly healthy granular surface has formed. This is usually in four and 
a half weeks, during which time the flap shrinks up considerably, and allows itself 
to become attached to the bone surface by secondary sutures (Plate XIII., I and K). 
The Knee. 
When disarticulation has been decided upon, it is best, if possible, to follow 
Brinton’s suggestion (1872) to preserve the semilunar cartilages. By this means 
the ligamentous covering of the knee is preserved, and all the fascial relations are 
preserved intact, which eventually prevents retraction and guards against the pro- 
jection of the condyles. This is totally contrary to the opinions of prosthetic 
writers of authority, who advocate a total abandonment of disarticulation at the 
knee, and who, judging purely from the standpoint of mechanical convenience and 
Fig. 268. 
Gritti’s osteoplastic supracondyloid knee amputation: patella utilized (Farabeuf), 
economy, universally claim that the ideal knee operation and point of selection 
should be three inches above the joint, and that Gritti’s supracondyloid operation 
affords much better stumps than a simple disarticulation (Fig. 268). All prosthetic 
mechanics do not deny, however, that a simple knee disarticulation offers any 
insurmountable obstacles to successful prosthesis, and, as this operation is unques- 
tionably superior from the anatomical and surgical (conservative) points of view, 
we shall give it due consideration (Plate XIII., I and K). 
The advantage of disarticulation over the simpler and more brilliant- 
looking amputation through or above the femoral condyles are many 
and striking: 
(1) There is less shock, less hemorrhage, less loss of limb, and less 
liability to infect the connective-tissue planes or marrow-canal; 
(2) Important muscular attachments are left undisturbed, and there 
is little muscular retraction ; 
(3) The stump is an excellent one, capable of great mobility and of 
bearing direct pressure. 
The conditions for a successful disarticulation are—(1) That the joint 
must be absolutely healthy, free from injury, disease, or infection; 
(2) that the necessary ample flap can be secured from the anterior AMPUTATION OF THE THIGH. 
617 
surface of the leg to thoroughly cover the large condyloid surface with- 
out tension; (3) that the patella and semilunar cartilages should be 
retained (this is not absolutely necessary, but desirable); (4) that the 
anterior surface of the stump shall be free from all scar-tissue. 
The length of the anterior flap-covering can be readily estimated by catting 
a flap from the anterior surface of the leg, which shall measure the length of the 
transcondyloid diameter of the femur, from the line bounding the patella to the point 
of anterior section in a semiflexed position of the limb. This will correspond, as 
a rule, to a point one inch below the tubercle of the tibia and will furnish ample 
covering for the condyles. 
Methods of Election.—Stephen Smith’s Bilateral (or “hooded 
flap ”) Method.—With a large scalpel commence an incision about one 
inch below the tubercle of the tibia, and cut to the bone; carry it down- 
ward and forward beyond the curve of the 
side of the leg, thence inward and backward 
to the middle of the leg, thence upward to 
the middle of the popliteal space. Repeat 
this incision upon the opposite side; raise 
the flap, consisting of all the tissues down 
to the bone, until the articulation is reached, 
divide the lateral ligaments, and enter the 
joint and sever its connections internally 
and externally. 
Be especially careful with the internal 
flap, which should be prolonged downward a little more than the external 
to provide sufficient covering for the internal condyle, which is longer 
and larger than the external. 
By this method a well-rounded stump is obtained with a cicatrix 
sunk in the intercondyloid fossa. 
Fig. 269. 
Stump after Stephen Smith’s ampu- 
tation at knee. 
Other methods of disarticulating the knee-joint that also comply with essential 
conditions of sufficient flap-covering, and that leave the scar-line in the posterior 
femoral surface, are the anterior elliptical incision (of Baudens), the circular with 
a posterior liberating incision (Chalot’s), the long anterior flap method of Pollock, 
and the bilateral flap of Pick; but none of these is superior to the hooded flap of 
Smith, previously described. 
Amputation of the Thigh. 
Through the Condyles.—The osseous section of the femur is made 
at the base of the condyles, about the level of the tubercle for the inser- 
tion of the abductor magnus tendon, or a little above this spot. At this 
level the medullary canal is not opened, as it begins one or two inches 
higher in the narrower part of the shaft. The saw-line corresponds to 
the epiphyseal line, which in children must be removed, for fear of 
secondary growth of bone and conical overgrowth of stump. If the 
patella is removed as in Carden’s amputation, great retraction must be 
expected in making the muscular section, and due allowance must be 
made for this in cutting the anterior flap. 
Methods of Election.— Carden’s transcondyloid (1846) consists in 
reflecting a rounded and semioval flap of skin and fat from the front of 
the joint (one diameter’s length from the point of osseous section), divid- 
ing everything else straight down to the bone, and sawing the bone 618 
AMPUTATIONS. 
slightly above the plane of the muscles, thus forming a flat-faced stump 
with a bonnet of skin to fall over it. The patella is divided immedi- 
ately above its upper border, and is thus excluded from the stump. 
Lister modified this operation by cutting a short posterior flap. 
Fig. 270. 
Fig. 271. 
Sabanejeff’s knee amputation (Chalot), 
Stump made as in Fig. 270 (Chalot). 
Gritti’s osteoplastic operation (1857) consists not only in removing 
the condyles, but also of sawing the articular surface of the patella and 
placing its cut surface upon the sawn condyles for the purpose of secur- 
ing union of the bones (Fig. 268). 
Fig. 272. 
Amputation of thigh hy Neudorfer’s method: periosteum retracted, chisel applied. 
Stokes’s supraoondyloid modification, which has been generally substi- 
tuted for the original Gritti, consists in dividing the femur higher up, at 
a point from one-half to three-quarters of an inch above the condyles. 
The section of the femur at this level is more nearly equal in size to that AMPUTATION OF THE THIGH. 
619 
of the divided patella. The patella at this point is not pulled up by the 
quadriceps as easily as in the lower or transcondyloid section of Gritti. 
The bones are kept in position, either by closely suturing the soft parts above 
the patella to the posterior flap or by wiring; which is unnecessary. Stokes also 
modifies the section of the soft parts, so that an anterior oval flap is fashioned 
which reaches from a point one inch above either condyle to a point just below the 
tubercle of the tibia. A posterior flap is also formed (Gritti cuts only one long 
anterior flap) which is at least one-third of the length of the anterior flap. 
Intercondyloul osteoplastic amputation of Sabanejejf (1890).—In some 
exceptional cases this operation may find application. It consists in 
making a section of the femur through the condyles. A section of 
tibia, including the tubercle with the patellar tendon attached, is then 
excised and sutured to the sawn femoral surface, as shown in Fig. 270. 
Through the Shaft and Upper Portion.—Conservatism should 
rule here. Save every inch of the femur up to the trochanteric line, 
and above this line disarticulate at the hip. Every method of amputa- 
tion has been applied here with greater or less success. 
Anatomical Points.—(1) The skin on the inner abductor and flexor surfaces 
has a great tendency to retraction; hence circular incisions through the lower 
Fig. 273. 
Same: soft parts sutured over the end of the hone. 
third should be made obliquely downward to compensate for the unequal retrac- 
tion of the skin. An oblique section will become a circular after the skin has 
retracted. 
(2) The thigh muscles retract very unequally when divided, this retraction 
being most conspicuous in the hamstring muscles posteriorly and on the inner 
side of the adductors, owing to their separate attachment to the pelvis. Hence the 
suggestion of Dawbarn, Brown, and others to tenotomize the hamstrings before 
amputation, so that full retraction may take place before the amputation is made. 
There are over twenty recognized methods of amputating the thigh, and there 
is considerable division of opinion among leading authorities as to which should 
be preferred, the circular or the flap method (Plate XIII., L). 
For the reasons given elsewhere we would unhesitatingly recommend 
the following section of the thigh, from the supracondyloid line of 
Gritti to the trochanters : 
The circular, modified by giving it sufficient obliquity downward to 
compensate for the cutaneous and muscular retraction, and by adding an 
external liberating incision on the outer aspect of the limb (Wyeth), 
or by making two liberating incisions on each side from the circular 
line to the level of the osseous section (Ravaton). Whenever the cir- 
cular is made, the subperiosteal or para peri osteal solid-flap section is 620 
AMPUTATIONS. 
referred to with very short skin-cufl‘. The preferred circular method 
is identical with that described in the section on methods of amputation. 
The bilateral solid flap (or hooded flap) method of Stephen Smith. 
The procedure is the same here as in the leg, and much simplified by 
the presence of one bone. 
Neudorfer’s Method.—This is virtually a circular with lateral lib- 
erating incisions—only differing in the fact that the osseous section is 
Fig. 274. 
Same: bone divided. 
made first and the flaps cut afterward. It is especially indicated when 
the disturbance of the soft parts and skin must be reduced to a mini- 
mum (amputation for senile and diabetic gangrene, etc.). 
By any of these three methods perfect, movable, well-protected, and 
well-padded stumps are obtained. The scar-tissue is all thrown back- 
ward, away from the terminus of the stump, owing to the secondary 
contraction of the flexors and adductors. 
The Hip-joint. 
Disarticulation at the Ilio-femoral Articulation.—The indications 
for disarticulation are furnished by all injuries or diseases which impli- 
cate the femur up to the trochanteric lines. The notable exception to 
this rule of conservatism is in malignant disease of bone, especially 
medullary growths connected with the middle and upper third of the 
femur. Here the tendency to recurrence will be diminished by disar- 
ticulating through the joint. 
Anatomical Landmarks.—The hip-joint is most accessible and easily opened 
from the front. The pubic spine is on a level with the great trochanter. The 
summit of the great trochanter is on a level with the hip-joint. The important 
vessels are the femoral and its branches, which lie on the antero-internal aspect 
of the joint. The femoral is separated from the capsule of the hip by the 
muscle, upon which it lies. The sciatic and its branches are the most important 
arteries. 
Special precautions must be taken against—(1) shock; (2) hemorrhage. 
Thorough haemostasis is the surest way of preventing shock. Prophylactic intra- 
venous injection of hot normal saline solution (about 40 gr. chloride of sodium to 
1 pint) is the most efficient mode of preparing a patient who needs stimulation. 
In every case in which shock exists, or there is traumatic anaemia from antecedent 
hemorrhage, inject the saline solution. In every case in which serious shock is 
apprehended expose the median basilic in the arm, and have it ready to receive 
the cannula and hot saline solution. THE HIP-JOINT. 
621 
Prophylactic haemostasis, with the view of controlling the femoral 
circulation, has been attempted with more or less success by several 
methods: Compression of the abdominal aorta mechanically with 
tourniquets, Lister’s, Esmarch’s, etc., or by the hand, of which Mac- 
ewen’s recently proposed ihethod is the best; compression of the common 
iliac through the rectum, mechanically with Davy’s lever; with the hand 
(Woodbury’s plan); by direct compression of the iliac trunks intra- 
peritoneally, or extra-peritoneally by compressing the common femoral 
over Poupart’s ligament with the finger; by preliminary ligation of the 
iliac or femoral arteries and veins; by elastic circular constriction, as 
adapted from Esmarch by Jordan; by Wyeth’s method, transfixing the 
limb with skewers which are passed transversely through the root of the 
limb between the joint-capsule and the artery, and compressing the soft 
parts above with an elastic cord tied in a figure of 8 ; or by using two 
skewers, one in front and one behind the femur (Tredelenburg and 
Newman); or by transfixing the thigh antero-posteriorly (Myles) and 
applying the figure of 8 laterally ; or by a preliminary dissection of the 
vessels and their compression with a special compressor (Dillon Brown, 
1895); or by excising the femoral head by external incision and com- 
pressing the anterior and posterior halves of the limb separately with 
elastic bands (Senn). 
All of these methods have been used with greater or less success by 
their inventors, and may have some advantages in special cases, but none 
can compare in their general application, thoroughness, simplicity, and 
wide range of usefulness with Wyeth’s method, which must be consid- 
ered the method of election. 
Wyeth’s Bloodless Method.—Steps.—(1) Expose the median 
basilic or cephalic in the arm in readiness for saline infusion. Place the 
patient with the trunk on the edge of the table. Lower the trunk. 
Fig. 275. 
Wyeth’s bloodless method: pins inserted and tube applied. 
Elevate the limb and milk it to empty it of blood, or apply Esmarch’s 
bandage from toes to trochanters according to general rules. 
(2) While the limb is still elevated or the Esmarch bandage is in posi- 
tion a large mattress needle or skewer, about three-sixteenths of an inch 622 
AMPUTATIONS. 
iii diameter and ten inches long, is introduced one inch below the ante- 
rior superior spine of the ilium and slightly to the inner side of this 
prominence. It is made to traverse superficially the muscles and fascia 
in the outer side of the hip, emerging on a level with, and about three 
inches from, the point of entrance. Another needle is now made to 
enter one inch below the level of the crotch internally to the saphenous 
opening, and, passing squarely through the adductors, comes out an inch 
below the tuber ischii. The points are at once shielded by bits of cork 
to prevent injury to the hands of the operator. No important structures 
are endangered by these skewers. A piece of strong white rubber tube, 
half an inch in diameter and long enough when tightened in position to 
go five or six times around the thigh, is now wound very tightly around 
and above the fixative needles and tied. If the Esmarch bandage has 
been employed, it is now removed. By using the skewers and con- 
strictor high up in this way the absolute occlusion of every vessel at the 
level of the hip-joint safely above the field of operation is secured, per- 
mitting the disarticulation to be completed and the vessels secured before 
the tourniquet is removed. 
(3) Division of the soft parts. In the formation of the flaps the 
surgeon must be guided by the condition of the parts within the field 
of operation. When permissible the following method seems ideal: 
About six inches below the tourniquet a circular incision is made, and 
this is joined by a longitudinal incision commencing at the tourniquet 
and passing over the trochanter major. A cuff that includes the sub- 
cutaneous tissues down to the deep fascia is dissected off to near the 
level of the trochanter minor. At about the level of the trochanter 
minor the remaining soft parts, together with the vessels, are divided 
down to the bone by a circular cut, and, in order to facilitate the search 
for the vessels, the soft parts are rapidly removed from the femur for 
several inches below the line of the divided muscles. 
At this stage of the operation the large vessels, veins as well as 
arteries, should be tied with good-sized catgut. Now leave the entire 
extremity intact, and use the full length of the limb as a lever in divid- 
ing the head of the bone. When the large and easily recognized vessels 
have been secured, the muscular attachments to the extremity of the 
bone are lifted off with scissors or knife, keeping along very close to the 
bone. After dividing the capsule of the joint forcible elevation, abduc- 
tion, and adduction of the thigh permit the entrance of air about the 
socket, and at the same time rupture the ligamentum teres. The dis- 
articulation is thus readily effected. Try to sever all known anatomical 
arteries before loosening the elastic constriction. In this, as in other 
amputations through thick muscular areas where small retracted arterial 
branches are likely to give trouble in finding them, after securing the 
main branches, such as the two femoral, circumflexes, and sciaties, it will 
be an expeditious plan to pass deep catgut sutures through the great 
masses of muscle all the way up across the cut surface, and to tie these 
firmly. In this way dead spaces are obliterated, the muscles are brought 
together, and compression exercised, which prevents bleeding. 
In some extremely weak cases in which shock is to be feared it may be safer to 
amputate the soft parts, secure the vessels, and saw through the bone, leaving the 
femoral head in the socket and the wound open and covered with an antiseptic or CA USES OF DEATH, ETC. 
623 
aseptic dressing. After the patient has fully recovered the enucleation of the bone 
can be safely effected. If in spite of ligatures and deep catgut sutures the oozing 
is considerable, the wound can be tamponed with a dry iodoform pack, over which 
the flaps are temporarily sutured with a view of securing firm pressure. 
At least forty-five other methods of disarticulating the hip could be described, 
but of all these we prefer to limit our selection to the preceding method, which is 
a composite of several of the older and best procedures, and because in its perfect 
haemostasis it exhibits the latest and most practical phase in the evolution of this 
once formidable operation. 
Causes of Death and Comparative Mortality after Ampu- 
tations. 
The immediate causes of death are—(1) hemorrhage; (2) shock; 
(3) exhaustion; (4) air- or fat-embolism; (5) accidental complications 
from the toxic effect of anaesthetics or pre-existing diseases. 
The secondary causes of mortality are the various infections; 
osteomyelitis; gangrene from atheroma or diabetes; secondary hemor- 
rhage. 
In considering the general mortality of amputations a comparison between 
the preantiseptic and the modern aseptic period will be instructive. Legouest, 
whose statistics were based upon the military experience of the Crimea, arrived at 
the following results: Fingers and metarcarpals, 13 per cent.; toes, 18.9; tibio- 
tarsal disarticulations, 23.2; metatarsal and partial foot amputations, 38; leg, 
49.9; thigh, 74; disarticulation of knee, 87 ; hip-joint, 87.7; wrist, 35 ; forearm, 
41.1; arm, 47.7 ; elbow, 48 ; shoulder, 59.5. 
Operations on the upper are less fatal than those at corresponding points on 
the lower extremities, because (1) they are smaller in size; (2) they are nearer the 
centre of the circulation ; and (3) they are less likely to suffer from septic infection 
(anus, genitals). 
The mortality of the modern period as exhibited in American 
practice is well shown by Dr. J. F. Erdman in his statistical report of 
703 major amputations from the records of eight leading hospitals of 
New York City.1 In ten years there were 703 single amputations, with 
109 deaths, or 15.5 per cent, mortality, irrespective of cause (injury or 
disease). 
By subdividing the whole group into sections Erdman’s statistics 
yield the following results: 
Wrist 1. per cent. 
Forearm .... 1.4 “ 
Elbow 0. “ 
Arm 18. 
Shoulder .... 25. “ 
Foot 7.8 per cent. 
Leg 12. “ 
Knee 13. 
Thigh ...... 21.5 “ 
Hip 34.4 
The mortality of the hip amputations is certainly here in excess of the 
results obtained by Wyeth’s method, as estimated by this author from 
the cases reported by various operators.2 
The most favorable results have been obtained by an American operator, 
W. L. Estes of Pennsylvania, who reports 294 single amputations, performed by 
himself, chiefly for traumatism, with a mortality-rate of but 4.6 per cent. The 
same surgeon reports 51 double synchronous major amputations, and 9 deaths, or a 
general mortality-rate of 17.66 per cent. This is a remarkably good result, con- 
sidering that the mortality until quite recently was enormous (44. per cent, in some 
of the best-equipped modern clinics; Schede). 
1 Vide Annals of Surgery, pp. 358-362, vol. xxii., 1895. 
2 Proceed. N. Y. State Med. Asso’n, Oct., 1893. 624 
AMPUTATIONS. 
The Stump. 
After the saving of life and the removal of the offending part, the 
object of every amputation is to provide a healthy stump that will 
render the greatest possible service to the bearer in after life. 
A good stump is characterized by its regular outline, its firmness, 
solidity, mobility, painlessness, and capacity for resisting friction and 
pressure at exposed parts. The bone should be amply covered, and the 
skin covering it should not be adherent to its surface ; the scar should 
be linear if possible, and completely hidden in a narrow groove in the 
most inactive surface. In shape, especially in the lower extremity, it 
should be like a gradually decreasing cone with a well-rounded outline 
and free from uneven surfaces. For prosthetic purposes it must be of 
sufficient length to provide leverage with which to swing an artificial 
limb, and possess the firmness to bear the contact with the socket, that 
both the natural and artificial socket may now move and be operated as 
one (Truax). 
The bad stump is characterized by a deficiency in the preceding 
qualities, and is usually associated with either one of the following con- 
ditions : viz. conicity (pathological or physiological), ulceration of the 
Fig. 276. 
Fig. 277. 
Ideal stump. 
Bad stump, because posterior flap was cut too 
short, and there has been great retraction 
of all soft tissues (Farabeuf). 
skin and other soft parts, necrosis of the bone, neuralgia. A bad stump 
may owe its evil properties to many conditions which are not necessarily 
associated with the method adopted during the amputation. An ampu- 
tation wound is liable to all the ills and misfortunes which may attend 
the course of any other traumatism. Thus sloughing of the skin, with 
excessive retraction of the soft parts, may be caused by defective nutri- 
tion of the extremity from constitutional conditions or pre-existing 
visceral lesions which interfere with the venous return or diminish the 
arterial supply (senile atheroma); from defective innervation, peripheral 
or central trophic lesions of the nervous system ; certain infections— 
viz. erysipelas, malignant oedema, also diabetes. After the stump heals 
a large weak scar-surface remains, which usually becomes painful and 
eczematous with the least provocation. Corns may also develop over 
exposed friction-points, or adventitous bursae may form which inflame 
easily and help to make the artificial limb intolerable. If the flap- 
covering is sufficient, the soft parts may retract to such an extent that 
the bone will project naked at the end or be merely covered with scar- 
tissue : this is the typical pathological conical stump. If the bone THE STUMP. 
625 
becomes infected, osteomyelitis and necrosis will follow. The rough or 
too rapid use of the saw during the amputation is not a rare cause of 
necrosis of the bone, which frequently necessitates reamputation. 
A secondary conicity of stumps is not rarely observed after amputations in 
children, due to the physiological growth of bone during development. This is 
also a not infrequent cause of reamputation, and must be borne in mind in pedi- 
atric practice. The stump may present a healthy appearance in every respect, and 
yet it may be very painful (the neuralgic stump), and thus be more than useless 
to its possessor. This neuralgic condition may be due to adhesion of nerves to the 
scar or pressure on these parts at friction-points, and is usually associated with 
bulbous enlargement or neuromatous tumors of the divided nerve-trunks. This 
is also largely due to the neglect of the precaution previously urged—i. e. to cut 
the nerves high above the original lines of amputation, so that they may be pro- 
tected and prevented from contracting adhesion to the scar. 
The Care of the Stump after Healing-, Preparatory to the Use of 
an Artificial Limb.—The tendency of stumps, especially those of the 
lower extremities, is to remain a long time enlarged and flaccid. When- 
ever the amputated extremity is allowed to hang in a dependent posi- 
tion it becomes oedematous and cyanotic from vasomotor paresis. In 
time, if not treated actively, it also develops a tendency to accumulate 
fat, which makes it so unwieldy and thick at its terminus that it inter- 
feres with the proper adjustment of the conical socket of the artificial 
limb. In amputations of the leg below the knee the stump will have 
a tendency to become flexed and the knee stiffened and ankylosed in 
consequence of the unbalanced traction of the powerful flexor muscles. 
The adjustment of an appropriate splint during the healing process, the 
frequent bathing of the limb with hot water and alcohol, daily move- 
ments of the joint, systematic massage, and, finally, the application of 
a firm roller bandage from the extremity to the root of the limb, will 
correct these difficulties and will rapidly prepare the stump for the pros- 
thetic appliance. 
How Soon after Amputation should an Artificial Limb be 
Applied ?—The time is variable and depends upon a multitude of con- 
ditions. The average period is three months (Agnew), but the safest 
rule is to allow just as long a time to elapse as is necessary for the 
thorough healing of the stump, and no longer (Cook). If too much 
time be allowed to elapse after the healing of the stump, the muscles 
become atrophied and inert, the joints stiffen, and a much longer prac- 
tice is required of the patient to acquire the necessary mastery of the 
artificial substitute for the lost part. CHAPTER XVI. 
ORTHOPAEDIC SURGERY. 
By Robert W. Lovett, M. D. 
Torticollis. 
Torticollis is the name applied to a condition characterized by a 
deformed position of the head, which is held to one side by a unilateral 
contraction of the sterno-mastoid and other muscles. This condition is 
also spoken of as wry-neck and caput obstipum. The affection is either 
congenital or acquired. 
Of the congenital form, (1) a class of cases occur where the condition 
is undoubtedly due to that obscure cause, call it what we may, which 
results in club-foot and similar deformities. In these cases the wry- 
neck is accompanied by other malformations. (2) Abnormal pressure 
in the uterus is undoubtedly the cause of some cases, and is manifested 
not only by the twisted position of the head, but in an asymmetry of 
the cranium and face, the side on which the muscles are contracted 
being the smaller. (3) Inflammation of the muscle undoubtedly occurs, 
as manifested by the pathological data about to be spoken of. (4) 
Affections of the nerve-centres and of the nerves themselves have been 
alluded to, but the theory rests upon no scientific foundation. (5) Rup- 
ture of the sterno-mastoid muscle, occurring perhaps at birth, is an 
undoubted cause of torticollis. Of late attempts have been made to 
deny the existence of hsematoma as a cause. A case, however, has been 
reported by the writer where a child was seen shortly after birth with a 
tumor in the sterno-mastoid muscle, evidently the result of a tearing of 
it. This case two years later showed a typical torticollis. 
Acquired torticollis results from muscular contraction—(1) due to 
exposure to cold, when it is probably rheumatic in origin ; (2) it results 
from unequal sight in the two eyes, which makes it necessary to hold 
the head to one side in reading, and which may result in a permanent 
contraction ; (3) contraction of the muscles, and consequently wry-neck, 
may occur from burns, injuries, or tumors; (4) it may be the result of 
a tonic or clonic muscular spasm due to some central or peripheral cause 
affecting the nervous system. It may also result from paralysis. 
Both congenital and acquired torticollis occur most often in children. 
Pathology.—The pathology of the affection has been determined 
by autopsy and by pieces of affected tissue removed during operation. 
In some instances the muscle appears normal. More often, however, 
the contractile tissue is replaced by fibrous tissue. This may be in 
small patches, in which case Volkmann1 and Vallert2 have assumed 
1 Cent. f. Chir., 1885, No. ]4. 
626 
2 Ibid., 1890, No. 38. TORTICOLLIS. 
627 
the existence of a “ fibrous myositis/’ or the whole muscle may be trans- 
formed into a tendinous band (Biindell/ Hensinger2). Shortening of 
the muscle on the affected side may be several centimetres (Bouvier/ 
Guyon4). In a case of congenital torticollis measured by Shaffer5 when 
the patient was six years old, and again when sixteen, the length of the 
muscle was found to be the same at both times. In old cases where the 
muscular substance has been replaced by fibrous tissue the muscle is 
adherent to the sheath by many bands, and in some severe cases the 
two structures become fused and cannot be identified (Duval,6 Bouvier). 
The sternal fascia is more often contracted than the clavicular. Asym- 
metry of the head and lower jaw exists in many cases (Nelaton, Broca, 
Eulenberg, Witzel7). After rectification this becomes more prominent 
than before. It is said that atrophy of the cerebral hemisphere of the 
contracted side may accompany the facial and cranial asymmetry 
(Diffenbach, Greffie,8 Broca9). 
Lateral curvature of the spine is apt to result from the abnormal posi- 
tion of the head in long-continued cases. In many cases, in addition 
to the contraction of the sterno-mastoid muscle, the posterior muscles at 
the side of the neck, and even the small vertebral muscles, may be 
affected. In some cases the contraction 
of these muscles predominates so much 
that the affection is spoken of as “ pos- 
terior torticollis.” 
Fig. 278. 
Secondary bony changes may occur as the 
result of long continuance of the abnormal 
position. The clavicles have been found of 
unequal length and the carotid arteries of dif- 
ferent size. Many theories have been advanced 
to account for the asymmetry of the head and 
face.10 
Symptoms.—The one symptom of 
torticollis is the abnormal position of 
the head accompanied by the usual 
muscular contraction. The ear of the 
affected side is brought nearer to the 
sternum, the face is rotated to the un- 
affected side, and the chin is somewhat 
elevated (Fig. 278). The whole head is 
generally tilted toward the affected side, 
but this varies with the degree to which 
the trapezius muscle is affected. The 
position of the head will vary in many respects according to the involve- 
ment of the different muscles. This position may be spasmodic or con- 
stant. If constant, reposition is not possible, and an attempt to rectify 
the position of the head results in bringing out as tense bands the sterno- 
Torticollis. 
1 Vogel’s Neue Med. Bibl., 1762, v. 189. 
2 Berieht von. d. Anthrop. Austatt. zu Wurzburg, 1826, p. 26. 
3 Leg. din. sur les Mai. de I’app. loc., Paris, 1895, pp. 77 and 85. 
4 Diet. ency. des Sc. med., 4me Serie, xvii. 670. 
5 Trans. Am. Orth.. Ass'n., vol. iv. p. 305. 
1 Deutsch. Z. fur Chir., xviii. 534. 
9 Quoted by Redard. 
6 Revue des Specialistes, 1843. 
8 Montpel. med., Nov. 16, 1890. 
10 Young, Orth. Surgery, p. 256. 628 
OR THOPJEDIC S UR GER Y. 
mastoid and other affected muscles on one side. Attempts to correct 
the deformity in the congenital form will not be painful, but in the vio- 
lent spasmodic form of the affection are generally accompanied by much 
pain. 
Diagnosis.—Although the diagnosis of torticollis is ordinarily an 
easy matter, it is sometimes difficult to differentiate it from cervical 
Pott’s disease, where a similar wry-neck is not uncommon. In Pott’s 
disease all the muscles of both sides resist passive movement and attempts 
at reposition of the head. Pain is almost sure to be present, very little 
movement in any direction is allowed, the temperature is probably ele- 
vated, and the other symptoms of tuberculous bone disease are present. 
In torticollis, on the other hand, asymmetry of the face is common, 
motion is allowed in any direction except where the muscles are con- 
tracted, and the contraction of the muscles is always unilateral. 
Again, true wry-neck may be simulated by sprains of the neck resulting from 
falls, which cause the head to be held stiffly to one side. Rheumatism of the neck, 
enlarged and inflamed cervical lymph-nodes, inflammation of the middle ear, and 
deep cervical abscess in the same way may cause a position of the head which 
simulates that of true torticollis. 
Prognosis.—The prognosis in congenital torticollis is not good so 
far as spontaneous recovery is concerned. The deformity progressively 
increases up to a certain point, when lateral deviation of the spine is apt 
to occur. Spasmodic torticollis, on the other hand, may recover spon- 
taneously. It may yield to medical treatment, but may persist for years 
unaffected even by operative measures. 
Treatment.—The treatment of congenital torticollis has been 
mechanical and operative. The treatment by apparatus is unsatisfac- 
tory, and for the most part abandoned in modern orthopaedic surgery. 
"Why this is the case is easily understood if one considers the patholog- 
ical condition. The older books on orthopaedic surgery contain pictures 
of an indefinite number of appliances used for this deformity, to which 
the interested reader is referred. The writer wishes to advocate only 
operative treatment except in the slightest cases, where a tentative effort 
at correction may be made by means of massage, head suspension, and 
vigorous manipulation. If it is desired to try mechanical treatment, 
the apparatus described in connection with the operative treatment is 
probably the best to be used. 
Division of the contracted sterno-mastoid muscle and other resistant 
structures is the modern treatment of torticollis. It may be done sub- 
cutaneously or by an open incision. The sternal part of the muscle is 
often the only part contracted, but operation almost always shows the 
presence of a much deeper contraction than is generally apparent, involv- 
ing the clavicular part also. Subcutaneous tenotomy is widely practised, 
especially in Europe, but when one considers the position of the internal 
jugular vein, which lies so closely under the clavicular portion of the 
muscle, most careful surgeons will prefer an open incision as being more 
thorough and less dangerous. 
This vessel has been divided in both methods of operation. Open incision 
exposes the muscle, either by a cut parallel to the clavicle and one inch above it, 
or by an incision along the anterior border of the muscle,.which leaves a less 
noticeable scar. The internal jugular vein is likely to be exposed in thorough 
operations. In intermittent torticollis division of the muscle is of little use, and LATERAL CURVATURE OF THE SPINE. 
629 
stretching, division, or resection of the spinal accessory nerve must be resorted to 
if electricity and mechanical treatment have failed. 
After division of the nerve relief is generally not immediate, but spasms per- 
sist for some time. Division of the posterior cervical nerves has been advocated 
under these circumstances. After operation the head should he maintained in an 
over-corrected position for two weeks at least. This is accomplished by confining 
the patient to bed and by applying to the head three strips of adhesive plaster to 
which weights are attached. By pulling in three different directions these roll the 
Fig. 279. 
Fig. 280. 
Apparatus for torticollis (by permission of the managers of the Children’s Hospital, Boston) 
head in the opposite position from that of the deformity. Maintenance of the 
head in a slightly over-corrected position is necessary for some months after 
operation in severe cases. This is most easily accomplished by the use of the 
apparatus devised by Dr. Buckminster Brown (Figs. 279 and 280), which is simple 
and efficient. It is shown in the figures. A Taylor back-brace with a head-support 
connected by ball-and-socket joint to the brace is the best of the appliances to be 
obtained of the instrument-makers, or a plaster-of-Paris bandage may be applied 
to the head and neck. 
Lateral Curvature of the Spine (Scoliosis). 
Lateral curvature of the spine, or scoliosis, is a deformity cha- 
racterized by a lateral deviation of part of the spinal column. This 
causes a change and inequality in the contour of the body. In all but 
the mildest cases the lateral deviation of the spine is accompanied by a 
rotation of the vertebral column on a vertical axis. Under these cir- 
cumstances the name rotary lateral curvature is applied to the condition. 
Although scoliosis may rarely exist as a congenital affection, it is then a de- 
formity due to intra-uterine rickets or to imperfect development of one half of the 
body. It was formerly thought that lateral curvature developed at the time of 630 
OR TJIOPsEDJC S UR GER Y. 
puberty, but later researches have shown that it occurs earlier in most cases. In 
1000 cases collected by Eulenberg, 85.8 per cent, showed the development of the 
deformity before the tenth year. Girls are, for some unexplained reason, atfected 
much more frequently than boys. In 2509 cases collected from various authors by 
Young, 2123 were girls and only 386 were boys. The deformity is much less fre- 
quent in America than in Europe as a rule, and, although some slight degree of 
lateral inequality is exceedingly common in our streets, severe cases are not often 
seen. 
The etiology of scoliosis may be formulated simply as follows: In 
general, the muscular development of these patients is below the aver- 
age and the circulation is less vigorous than it should be. The digestion 
is often poor and the children are most often poorly nourished. Ocular 
defects may be present. These conditions may be spoken of as predis- 
posing causes. In considering the immediate causes of the deformity in 
certain cases it is plainly evident what the causation was, but in the 
majority of cases this immediate cause lies hidden in the deepest obscur- 
ity, and, although many fanciful theories have been adduced to account 
for it, it certainly seems more scientific to admit that in the majority of 
cases of scoliosis we cannot speak definitely as to the immediate cause. 
Among the cases where the causation is plain may be mentioned those 
resulting from (a) empyema, (b) infantile paralysis, (c) cerebral paralysis, 
(d) hereditary locomotor ataxia and pseudo-hypertropliic paralysis, (e) 
rickets, (/) marked inequality in the length of the legs, (g) certain occu- 
pations necessitating the use of one arm, (h) the loss of one arm and 
similar changes, (i) torticollis. The remainder of the cases cannot be 
accounted for in any such obvious way, and certain theories have been 
advanced to account for their origin. These are as follows : (1) that 
unequal muscular action or that a unilateral muscular contraction causes 
the deformity : evidence is wanting to show primary weakness of the 
muscles; (2) that the affection is due to unequal bony growth of the two 
sides; (3) that the superincumbent weight of the body comes upon the 
spinal column held in a faulty position. 
In some experiments on the cadaver undertaken by Bradford it was demon- 
strated that when downward pressure was exerted upon the spinal column held in 
an oblique position a lateral bending took place when a certain point was reached, 
which reproduced the features of a true scoliosis. The more obliquely the weight 
came upon the column, the more marked was the scoliosis. It is in this wray that 
faulty attitudes may cause lateral curvature. 
Each one of these theories accounts, of course, for certain cases, but it must be 
evident that no one is worthy of general application. 
The pathology throws no light upon the causation of the affection, 
and onlv serves to accentuate the importance of early and vigorous 
treatment. In the early stages of the affection no pathological changes 
are noticed, and in the later stages the pathological changes are such as 
result from the prolonged maintenance of a vicious position. The effects 
of pressure are noticed in the atrophy of the parts of the vertebrae in the 
concavity of the curve, resulting sometimes in a change from the nor- 
mal shape of the vertebrae to that of a wedge. The vertebrae are 
rotated on a vertical axis, and the atrophy from pressure results in 
locking the column in its twisted and distorted position. The muscles 
and ligaments are contracted on the concave side and stretched on the 
convex side. The intervertebral disks atrophy from pressure on the 
concavity, and the ribs are separated on the convex side and crowded LATERAL CURVATURE OF THE SPINE. 
631 
together on the coneave side. They may be so depressed as to reach or 
even lie inside of the crest of the ilium. The chest is distorted and 
compressed on the convex side, and the abdominal organs may be dis- 
placed downward. 
Symptoms.—Much obscurity has been added to that naturally sur- 
rounding the study of lateral curvature by the introduction of various 
terms and subdivisions into varieties and into single and double curves, 
etc. The condition in question is really this: A 
persistent lateral deviation of the spine may occur 
in any part of the dorsal or lumbar region. The 
convexity of this curve may be to the right or to the 
left, and it may involve only a few or it may involve 
many vertebrae. When once a curve in the spine 
has occurred, it is easy to see that either the person 
must lean over to one side or that the vertebrae above 
or below the curve must make a compensatory bend 
in the opposite direction, by which the general up- 
right position of the body may be maintained. This 
happens instinctively, and with the dorsal curve to 
the right one finds a lumbar curve to the left, and 
probably a cervical curve also. The original curve 
is at the root of the mischief, and is spoken of as 
the primary curve. The others, which are only 
incidental, although necessary for equilibrium, are 
called secondary or compensatory curves. 
For some unknown mechanical reason, when the 
lateral curve has reached a certain degree, which 
varies in different individuals, the vertebral column 
begins to rotate on a vertical axis, carrying with it, 
of course, the ribs. The thorax no longer lies in 
the same lateral plane as the pelvis. So much has 
been written to account for this rotation, all of 
which is unsatisfactory, that the references only are 
given.1 
Fig. 281. 
The rotation of the vertebral bodies is toward the con- 
vexity of the curve; that is, in a right dorsal curve—the 
angles of the ribs are carried backward on the right side, 
while the left side of the chest becomes more prominent 
in front. The most common form of lateral curvature is 
where the dorsal spine curves to the right (Fig. 281). 
The lateral deviation of the spine itself is rarely 
noticed by the parents, bnt rather some of the 
changes are seen which it occasions in the contour 
of the body. Round shoulders are in many instances, especially where 
weakness of the muscles is present, the first indication of beginning 
trouble. The flexion of the spine, however, is rarely appreciated in its 
true significance, and many a case of serious scoliosis might be prevented 
if every case of round shoulders were investigated as to the presence of 
beginning lateral deformity. Most often scoliosis is discovered by one 
of the following signs : The prominence of one hip ; the elevation of one 
Eight dorsal curvature as- 
sociated with talipes 
equinus of left foot. 
1 A. B. Judson, N. Y. Record, Sept. 30, 1882; Jan. 19, 1884; Nov. 1, 1890. 632 
OR TITOPJEDIC SURGERY. 
shoulder; the backward projection of one shoulder-blade; the greater 
prominence of one clavicle; the fact that the skirt of the dress hangs 
unequally on the two sides; the difficulty in fitting the waist of a tight 
dress on account of the greater distance from the armhole to the waist 
on one side. It is these trifling and apparently irrelevant signs that 
most often lead to an examination of the child. The dressmaker is in 
very many cases the first person to call attention to the condition. 
The mobility of the spinal column is not at first affected, but later stiffness of 
the affected portion generally occurs. Hence comes a very practical division of 
scoliosis into three grades: (1) lateral deviation with no perceptible rotation on a 
vertical axis; (2) lateral deviation with rotation, but with no perceptible stiffness 
of the spine; (3) lateral deviation with rotation and stiffness. Subjectively, the 
patient rarely notices the condition. Pain is present only as a coincident neuralgia 
or as the result of muscular fatigue. Dyspnoea may occur in severe cases as the 
result of diminished chest-capacity. Limping at times may be present in the 
severest cases on account of the drawing up of the pelvis on one side by the extreme 
spinal curve. The condition is, in short, a lateral deviation of some part of the 
spine, not the result of any disease of the bone, but apparently induced by some 
inequality in muscular force and the distribution of superincumbent weight. 
Diagnosis.—From what has been said, it will be seen that the 
diagnosis of scoliosis in slight cases is more likely to be made from 
the effects of the curvature than from the curvature itself. The 
existence of round shoulders is always suspicious. For examination 
the patient, if a child, should be stripped to the hips and examined 
from in front and behind. Older girls should be covered in front by a 
common apron tied by strings around the neck and allowed to fall over 
the chest and abdomen. Examined from in front, especially at a little 
distance, it will be seen, even in slight cases, that one arm hangs farther 
out from the side of the body than the other; that the side of the body 
is more hollow above one ilium than above the other, which gives the 
appearance of the greater prominence of one hip; that the shoulders 
are not on the same level ; and that in certain cases a lateral deviation 
of the whole trunk is noticed. The nipples may be noticed to be not in 
the same horizontal plane. In severe cases these signs will be more promi- 
nent, and one side of the chest will be seen to stand farther forward than 
the other; often it will be seen to be only a one-sided pigeon breast; 
again, one half of the thorax will be decidedly prominent. In severe 
cases the unequal prominence of the clavicles will be well marked. In 
slight cases lateral deviation of the spine is more readily detected from 
the front than from the back. When examined from behind, the spine 
can be made red by drawing two fingers along the spinous processes, 
when a red streak will show plainly the lateral deviation. In slight 
cases one notices the unequal outline of the two sides of the body, but 
less distinctly than from in front. The angles of the scapulae are seen 
to be on different levels, and the inclination of the whole trunk may 
again be evident here. In severe cases rotation is noticed by the greater 
prominence of one scapula, or, if the curve is a lumbar one, by the 
prominence of the lumbar transverse processes on the convex side of 
the curve (Fig. 283). The presence of rotation should be searched for 
by directing the patient to bend forward as if making a bow while the 
knees are kept stiff and the arms allowed to hang. When the verte- 
bral column becomes horizontal in this position, if one glances from LATERAL CURVATURE OF THE SPINE. 
633 
behind the slightest rotation of the vertebrae can be detected by a prom- 
inence of one side of the spine in the dorsal or lumbar region. Where 
the rotation has occurred in a right dorsal curve, in this position an 
elevation on the right side of the vertebral column can be noticed if any 
backward rotation is present (Fig. 283). 
By following in detail the methods described above no case of lat- 
eral curvature need escape detection. 
The flexibility of the spine is tested by allowing the patient to hang from a 
bar or by manual attempts at reposition. Recumbency on the face will obliterate 
Fig. 282. 
Fig. 283. 
Photograph of case of left dorsal scoliosis. 
Characteristic appearance of scoliosis 
in the stooping posture. 
the curve at an early stage. The length of the legs should be measured to see 
that the curve is not the result of some inequality. 
Scoliosis resembles at times the lateral deviation of the spine which occurs in 
Pott’s disease. The absence of the symptoms of Pott’s disease, accompanied by the 
characteristics of the curvature described above, will be sufficient for its detection. 
Many complicated and ingenious machines have been devised to record cases 
of scoliosis, but photography is, on the whole, the most satisfactory method. The 
photographs are more serviceable if the patient stands in front of a screen on which 
squares are marked out by black threads (Fig. 284). 
The prognosis in scoliosis is one of the most unsatisfactory parts of 
the study of the condition. In a given case it is exceedingly difficult 
for even the most experienced to predict whether or not further deform- 634 
ORTHOPAEDIC SURGERY. 
itv will occur. Spontaneous recovery seems to occur at any stage in 
every variety of case. The spontaneous cure of the deformity, when 
once it has become enough, for example, to be plainly evident through 
the clothes, is extremely unlikely to 
occur. For mechanical reasons it 
is obvious that it is likely to grow 
worse. 
Under favoring conditions and long- 
continued treatment cases of the first 
grade should be cured; cases of the sec- 
ond grade should be much bettered as to 
the lateral deviation ; and probably cases 
with slight rotation should improve. The 
writer is skeptical whether it ever en- 
tirely disappears when once it has reached 
any marked degree. Cases of the third 
degree can be improved in the matter of 
lateral curvature, and can be made taller 
and more comfortable even in neglected 
cases treated in adult life. For example, 
a woman of thirty years with a most un- 
sightly curve of fifteen years’ standing 
increased two inches in height during 
one year’s treatment. Improvement is 
retarded, and treatment even in mild 
cases must cover six months or a year, 
and in severe cases from one to three or 
more years. Relapses are common when 
treatment is irregular or if it is stopped 
too soon. 
Treatment.—There is little 
agreement among surgeons as to the 
best treatment of lateral curvature. 
At best it is slow and uninteresting, 
and if the attendance is irregular 
or if the methods are incomplete, 
progress is unsatisfactory. 
The conditions to be met are these : The spinal column is curved to 
one side; the superincumbent weight tends to increase this curvature; 
rotation on a vertical axis may be present, and stiffness is sure to inter- 
vene in time if the vicious position is maintained. The problem of treat- 
ment is to straighten this column and to hold it in the correct position. 
If stiffness be present, flexibility must be restored—(a) by braces, (6) by 
manipulation and apparatus. After flexibility has been restored so far as 
possible, or if stiffness be not present, the column must be held in the cor- 
rect position (2a) by braces and (26) by the muscles. It is hoped that 
this statement of an almost self-evident problem may relieve the subject 
of much needless obscurity. 
(a) Attempts to straighten a stiff curvature by means of braces 
are for the most part at present confined to the instrument-shops. Enor- 
mously clumsy and heavy appliances with screws and pads and springs 
have been much used, and can be found figured in any orthopaedic 
treatise. They need not be discussed here, for they are mechanically 
inefficient. It is plain that a curved spinal column where rigidity is 
present cannot be straightened by an apparatus which obtains so little 
Fig. 284. 
Left lumbar curvature (by permission of the 
managers of the Children’s Hospital, Boston). LATERAL CURVATURE OF THE SPINE. 
635 
hold as these, or which works at such a great disadvantage in the matter 
of pressure. 
The plaster jacket, or Lorenz’s modification of it as a plaster girdle, may be 
applied with benefit for a few days at a time to severe cases. The curve is cor- 
rected as much as possible by bending to one side or by suspension with lateral 
traction to pull the column as straight as possible. In the corrected position a plaster 
jacket or girdle is applied and allowed to harden. Repetition of this process for 
several times, with intervals of three to six days, will often produce much improve- 
ment in a bad curve for the time being, but the improvement must be held by other 
means and the process is most uncomfortable. 
(b) Attempts to Straighten a Stiff Column by Manipulation 
and Apparatus.—The object of these attempts is by pressure against 
the convexity of the curve, either intermittent or continuous, to stretch 
contracted ligaments, fasciae, and muscles. It does not matter whether 
the force applied is manual or instrumental. Where stiffness is slight, 
self-suspension by a Sayre head-piece should be practised, perhaps daily, 
or the patient might hang from a bar by both arms, and in all but the 
slightest cases some one should press from the side against the convex 
side of the curve. 
The gymnastic exercises to be described later will restore flexibility in the 
milder cases. These are, in general, such exercises as tend to throw the body into 
a position which diminishes the curve. Severe cases need more forcible measures. 
In a right dorsal curve, for example, a manipulation much used by Dr. Shaffer is 
very useful. The patient sits on a stool in front of the surgeon between his 
Fig. 285. 
Self-correction apparatus for lateral curvature (Bradford). 
knees, with her back toward him. The surgeon, sitting on a similar stool, leans 
his right elbow on his right knee and places his right hand, opened flat, opposite 
the convexity of the patient’s curve. He raises his left arm and places his left 
hand on the root of the patient’s neck at the left side. With a slight rotary and 
shifting motion of the left arm he throws the patient over to the right, so that her 636 
ORTHOPAEDIC SURGERY. 
weight comes upon his right arm and knee. This should be repeated several times 
with as much force as the surgeon thinks best. 
Perhaps the simplest form of mechanical apparatus for restoring 
flexibility is the one described by Bradford (Figs. 285, 286), where 
self-suspension is combined with lateral pressure by means of traction 
bands. A more forcible machine for applying pressure by screws is 
shown in Fig. 287. These are used as often as necessary, and if possi- 
ble the curve is over-corrected. The application of such force is not 
painful. It may be said, again, that the object of such manipulation is 
to overcome any stiffness of the spinal column, so that whatever treat- 
ment is applied may be to a flexible column. 
(2a) Attempts to hold a Flexible Column Straight by Braces.— 
Where stiffness has not begun or where it has been overcome the prob- 
lem of holding the column straight is the one upon which the cure or 
Fig. 286. 
Self-correction apparatus for lateral curvature (Bradford), 
improvement of the case depends. In former years the whole treatment 
of lateral curvature has revolved around the question of, What brace 
does this most efficiently? It is more pertinent to ask (and this ques- 
tion is being asked), Is it better to use a brace or to educate the muscles 
on one side of the column to serve as a support? Any appliance which 
takes the place of the muscles anywhere in the body, and prevents their 
use, unquestionably weakens those muscles. This is the chief objection 
to the routine use of braces in lateral curvature. Again, any appliance 
which attempts to hold straight a spinal column by a hold upon the pelvis 
and the movable thorax, while the force of gravity works all the while 
against it, is necessarily at a great mechanical disadvantage. Other 
things being equal, it is plain that the best results would come from 
the education of faulty muscles rather than by supplementing them by LATERAL CURVATURE OF THE SPINE. 
637 
apparatus. Whether or not this can be done is largely a matter of indi- 
vidual opinion. The writer believes that the rational method of obtain- 
ing improvement, and cure where possible, in lateral curvature lies in 
the education of those muscles which tend to overcome the spinal curve. 
It is obvious that these muscles cannot be developed immediately to their full 
capacity—indeed, that their development is a very slow matter—and the question 
arises whether it is better in the early stages of treatment, after having restored 
as much flexibility as possible to the column, to hold it in its improved posi- 
tion by means of braces while muscular development is going on, or to depend 
entirely upon the muscular education for this correction. This must be deter- 
mined by the muscular strength and the effect which such treatment has upon the 
position. Where the corrective effect of 
the exercises is felt for some time, it is 
safe to allow the patient to go without a 
brace; but where the muscles are obvi- 
ously weak and the effect of such exercise 
is soon lost, it is manifestly better to use 
some sort of a supporting apparatus be- 
tween the exercises. In most cases the 
writer finds it possible not to use braces 
at all, restricting their use to those cases 
where the muscles are exceptionally weak, 
where growth is rapid, where the deform- 
Fig. 287. 
Fig. 288. 
Patient in position in correcting apparatus 
(Bradford and Brackett). 
Supporting jacket cut and laced for removal 
(by permission of the managers of the Chil- 
dren’s Hospital, Boston). 
ity is extreme, or where it is impossible to obtain frequent gymnastic exercises. 
Some surgeons, however, believe in the routine use of braces: 
(1) The plaster-of-Paris or leather or paper jacket applied during suspension, 
and cut and laced to permit its removal for daily muscular exercise (Fig. 288). 
(2) The brace of I)r. Shaffer, which aims at correction of the rotation as well 
as of the lateral curvature (Fig. 289). 
(3) The brace of Dr. Taylor (Fig. 290). 
The two latter are difficult to fit and require the services of an expert instru- 
ment-maker. 638 
ORTHOPAEDIC SURGERY. 
Almost numberless braces are figured in every orthopaedic Surgery. For the 
most part, they are of little or no value, and to works of former years the reader 
is referred should he desire to know more about the treatment by braces.1 In 
Fig. 289. 
Fig. 290. 
Shaffer spine-brace applied to case of left dorsal 
scoliosis (Young). 
Taylor’s brace: right dorsal curvature. 
general, except in cases where heart or lung disease is present or in very excep- 
tionally weak persons, braces should only be used in connection with manipulation 
and exercises. 
(26) Attempts to hold a Flexible Column Straight by Mus- 
cles.—When the column has been made flexible or has never been stiff, 
the development of the muscles on the convex side of the curve is, in 
general, as has been said, the most rational corrective measure. 
If the ends of a flexible rod, a b, have been connected by two elastic bands, 
c d, and if one (d) were twice as strong as the one on the other side (c), the rod 
would bend with the convexity toward c. The easiest way to correct this would 
be to replace c by a band as strong as d, in which case the rod would become 
straight again ; that is, to strengthen the traction force on the convex side of the 
curve is to work toward the obliteration of the curve. This demonstration, which 
any one may make for himself, makes it unnecessary to discuss whether the mus- 
cles on the convex or concave side of the curve should be attacked. The spinal 
column is not a rod flexible in one plane, but the conditions of the experiment are 
to a certain extent applicable. Assuming, then, that the muscles of the convexity 
should be developed, the general muscular development must also be regarded, 
especially in connection with the extensor muscles of the back. The chest should 
1 Taylor, Am. Orth. Assn. Trans, vol. iii. p. 143, Fig. 6. LATERAL CURVATURE OE THE SPINE. 
639 
be expanded, the abdominal muscles strengthened, and, as far as possible, a cor- 
rect carriage should be taught. The Swedish system of Ling excels in its ability 
to isolate certain groups of muscles from work and other groups of muscles for 
work. It matters little what system the 
surgeon uses, as long as he is able to pick 
out a certain group of muscles to exercise. 
Certain exercises should be general; cer- 
tain others should be distinctly unilateral. 
Fig. 291. 
If gymnastic exercises are able to 
do good, they must be equally power- 
ful for harm. Consequently, accuracy 
is essential. It is not intended here, 
nor would it be possible, to give any 
one scheme of exercises suitable for 
the treatment of lateral curvature. 
Each case must be treated upon its 
individual merits, and the exercises 
must be adapted to the location of 
the curve. A position is assumed 
which by contraction or by relaxa- 
tion of certain groups of muscles, 
which it is not desired to exercise, 
isolates them from further work. 
Then a unilateral movement is taken 
which shall exercise a certain group 
of muscles as often as the movement 
is repeated. 
As an example of this, we will take 
the following: Technically, it is known as 
hands, neck, rest, left foot, walk, standing 
position, trunk-turning, and bending to 
right. In the primary position, before bending is begun, the left lumbar muscles 
are made to contract on account of the position of the left leg. The right lumbar 
muscles are relaxed by the hyperextended position of the right leg. The hands 
at the neck hold the neck muscles along with the arm muscles in a condition of 
contraction, which prevents them from doing further work; they are thus isolated 
by being in contraction. By bending and turning the trunk to the right several 
times the right dorsal muscles are alone active and contract strongly. This exer- 
cise is suitable for some cases of right dorsal curvature, inasmuch as it contracts 
the muscles of the convexity of a dorsal curve. Incidentally the left lumbar 
muscles are also contracted. 
Another exercise is known as the stretch stride standing, trunk bending to 
left side. The separation of the legs holds the pelvis square. The arms being 
extended upward above the head, isolate from further work the arm, scapular, and 
upper dorsal muscles by placing them in contraction. A bending to the left, 
made either with or without resistance, is accomplished entirely by the left lumbar 
muscles. Such an exercise serves as an instance of isolation of muscles for exercise 
in a case of left lumbar curvature. 
The exercise for the isolation of the erector spin* muscles is known as the 
neck, rest, prone, sitting extension of trunk with resistance on lumbar region. 
The scapular and upper dorsal muscles are isolated by the position of the arms, 
which are held behind the head. The leg muscles are isolated from work by the 
sitting position, and the straightening of the body against resistance is accom- 
plished almost entirely by the erector spinse muscles. 
High degree of rotary-lateral curvature. 
These exercises, selected at random, serve to illustrate the exactness 
and the reasonableness of the Swedish system of gymnastics. In itself 
it has no place for forcible correction, which to the writer’s mind in 640 
ORTHOPEDIC SURGERY. 
severe cases is a necessary part of any successful system of treatment. 
In so far as treatment by muscular education goes, it may be said that 
the principle is simply the systematic and continual exercise of the 
muscles on the convex side of the curve, taken in connection with a 
certain amount of developmental general exercise, and in connection, 
if need be, with forcible correction to restore flexibility to the stiffened 
column. In a general way, the contraction of muscles on the convex 
side of the curves will throw the body into a corrected position, spoken 
of by Roth as the “ keynote ” position. 
Massage to the weaker muscles is an adjuvant to the treatment. 
Cases should be treated as often as possible—once or twice a day if feasible, 
three times a week at least. The more frequent the exercises the better the results. 
After treatment the patient should lie still at least one hour. Relapses are not 
infrequent where treatment is discontinued too soon. It is not likely that the 
maximum of improvement will be reached even in a slight case in less than six 
months of active treatment and six months of a continuation of exercises. Elec- 
tricity may be of some use, but it is only a detail of treatment. 
The writer has passed by without mention the great majority of 
appliances and measures in use in former years and to a certain extent 
still in use to-day. This has not been done carelessly, but simply to 
strip the treatment of all unnecessary detail and to present only what 
seemed essential. It may be repeated that the treatment, in a word, 
consists in rendering a stiff column flexible and educating the muscles 
to hold the column in an approximately proper position. As an adjunct 
to this treatment the use of braces may be necessary. 
This is an affection of considerable rarity, which may occur alone or 
in connection with other deformities, such as club-foot, hare-lip, and the 
like. It is by far the most common of the congenital dislocations and 
may affect one or both hips. 
Dislocation of one hip is twice as common as double dislocation, and for some 
unexplained reason girls are affected much more frequently than boys; of 341 
cases collected by the writer, 301 were girls. Lorenz,1 in 671 cases analyzed, found 
87.8 per cent, of girls among those affected. There were among these 245 double 
dislocations and 421 single dislocations. 
As to the causes of this deformity, there has been much speculation. Certain 
cases are undoubtedly caused by injury at birth, and although these cannot prop- 
erly be classed as congenital dislocations, yet they resemble them so closely that 
they are not recognized separately. Other cases are undoubtedly dislocated by 
traumatism during intra-uterine life, but the majority of cases must be accounted 
for, as are other congenital deformities, by an arrest of development of the acetab- 
ulum. The Y cartilage at the bottom of the socket fails to carry on the growth 
of the three segments which form the acetabulum.2 The head of the femur in 
these cases may reach the normal size, and the stunted acetabulum is not large 
enough to hold it in place. In other cases, and more often, the head of the femur 
is small and imperfect; it may be entirely wanting, and intermediate conditions 
are present. In the great majority of cases the head of the femur is found to rest 
upon the dorsum of the ilium, either upon the bone itself or upon the gluteus 
minimus muscle. The acetabulum in general is smaller and shallower than nor- 
mal, and seems to be filled with fat, connective tissue, and cartilaginous substance 
which can be scraped away with a curette. The capsule of the joint—upon which, 
Congenital Dislocation of the Hip. 
1 Lorenz, Path, und Ther. der Aug. Huftverrenkung, 1895. 
2 Grawitz, Virch. Arch., 1878, lxxiv. p. 1. CONGENITAL DISLOCATION OF THE HIP. 
641 
of course, the chief part of the body-weight rests in walking—is much hyper- 
trophied, thickened, and stretched. Where the congenital dislocation is of long 
standing the part of the capsule which lies between the head of the femur and the 
new socket may be worn away, and the capsule appears in this case to be attached 
to the rim of the new acetabulum. In short, the capsule with the pelvi-trochan- 
teric muscles has become only a tough suspensory ligament. The pelvi-trochan- 
teric muscles are all stretched. If the new acetabulum forms directly over the old 
one, the pelvis remains in practically the normal plane, and but little lordosis is 
present; if, however, the new socket develops posteriorly, the pelvis tilts and 
marked lordosis results. The upper part of the pelvis is constricted and the lower 
part elongated in later life. The ligamentum teres may be normal, but is most 
often wanting or subject to various irregularities. 
Symptoms.—Children with double dislocation (Fig. 292) are, as a 
rule, late in walking, and when they do, they show a rolling gait and an 
Fig. 292. 
Fig. 293. 
Double congenital dislocation of the 
left side. 
Unilateral congenital dislocation of the left hip, 
showing the natural position in standing 
(Lovett). (By permission of the Trustees of the 
Fiske Prize Fund.) 
exaggerated swaying of the body from side to side which resembles the 
gait of extreme bow-legs. The trochanters form a well-marked prom- 642 
ORTHOPAEDIC SURGERY. 
inence posteriorly, and the view of the back of the child shows a bow- 
ing forward of "the lumbar spine, which is all the more striking on 
account of the projection of the trochanters through the glutei muscles. 
The legs are farther apart than they should be normally when viewed 
from in front, and the perineum is unduly broad. The children rarely 
complain of pain and are well developed in other respects. When 
single deformity is present, the child limps distressingly on the affected 
side at each step, and shows a gait which is simulated only by severe 
infantile paralysis of one leg. The affected leg is generally shorter 
and smaller than the well one, and on account of the elasticity of the 
suspensory ligaments it is impossible to correct the limp entirely by a 
high sole on the short side. 
Diagnosis.—The diagnosis is not always easy. In theory one 
should be able to detect dislocation of the hip by drawing Nelaton’s 
line on the skin and seeing if the trochanter projects above it. In 
young children this is not always an easy matter to do, and the diag- 
nosis is sometimes one of much difficulty. One has to rely on the 
shortening, the abnormal mobility of the joint, the presence of a click 
as the head slides over the rim of the acetabulum, and in most cases 
the elevation of the trochanter. If the limb be pulled downward with 
the hand or forward when flexed to a right angle, it can generally be 
felt to yield. Rotation will often demonstrate the head of the femur 
and its approximate size. 
The fact that a well-marked click in the hip-joint is present in manipulation 
is suspicious, but is not a definite sign. Rhachitic bending of the neck of the femur 
may resemble congenital dislocation, inasmuch as the trochanters lie above N61a- 
ton’s line, and the gait of those affected is rolling and like that of congenital dis- 
location, but the bones forming the hip are firmly in place. 
The affection need never be confused with hip disease. 
Prognosis.—Without operation there is little prospect of improve- 
ment. Some cases grew worse as puberty is reached, while others 
improve somewhat. 
Treatment.—The earlier methods of treatment by continuous ex- 
tension in bed or by means of ambulatory apparatus making traction 
have been for the most part abandoned, because not only must the 
treatment be very long and irksome, but the results have not been 
satisfactory and relapses have been common. Apparatus may be of 
some use. Lorenz and Hoffa are both advocates of the use of a corset 
in cases which cannot be operated upon, especially cases of double dis- 
location. These corsets hold tightly to the pelvis and are padded to hold 
down the trochanters. Improvement, however, may be brought about 
by continued traction lasting from two to live years, but few patients 
are so situated that they are either willing or able to pursue so long a 
treatment. Traction by heavy weights as a preliminary to operation 
in older and more difficult cases is advocated by some writers (Lorenz). 
Treatment by traction alone is not to be recommended. 
Tenotomy of the peritrochanteric muscles and subcutaneous division of the 
fasciae and muscles, as pursued by Adams and Barwell, have been abandoned. 
Excision of the joint has not proved a satisfactory measure for the relief of the 
condition. Of 27 cases analyzed by the writer, 3 could be classed as good results, 
5 were moderate results, and 8 were bad results. As a curative measure ex- 
cision of the head of the femur cannot be recommended as a mode of treatment. CONGENITAL DISLOCATION OF THE HIP. 
643 
The injection of a 10 per cent, solution of zinc chloride into the affected hip-joint 
has been advocated by Lannelongue for the purpose of exciting a bony growth at 
the seat of the injection. So far as known, the treatment has not been followed 
out in America. 
The method of Paci1 has attracted considerable attention. The child 
is etherized, and the movements of reduction of an ordinary traumatic 
dislocation are made slowly, forcibly, and accu- 
rately. First the limb is hexed, then abducted, 
rotated externally, and extended. After correc- 
tion a plaster-of-Paris bandage is applied along 
with traction of 4 to 10 kilogrammes. After 
some months a corset is applied and the child 
allowed to go about. The hip is protected thus 
for nearly a year and a half after operation. 
Fig. 294. 
Paci reports as operated on by this method 22 cases 
of single luxation and 2 of double, in all of which 
he had good results. The author quotes favorable opin- 
ions from many surgeons, but the weight of opinion is 
against the method. Post of Boston many years ago 
obtained a fair result from a forcible reposition like 
this, which shows that some cases can be easily cor- 
rected. Lorenz speaks of the method as one chiefly 
useful in the hands of its originator. It has had little 
use in America. 
The operations devised by Hoffa and Lorenz 
have the greatest claim to surgical attention. 
Hoffa’s operation aims at relieving the con- 
traction of the periarticular soft parts by a free 
incision of the capsule and peritrochanteric mus- 
cles, and at replacing the head of the femur in 
an artificial socket made by deepening the orig- 
inal acetabulum. Hoffa advocates a posterior 
incision as if for excision of the hip. The pos- 
terior aspect of the joint is exposed ; the capsule 
is opened and extirpated in so far as it offers any 
resistance to reduction. Any resistant bands 
which prevent the femur from being pulled down 
are cut. If necessary the hamstring muscles 
and adductor tendons may be divided. The 
original acetabulum is deepened and widened with a heavy sharp 
curette. The head of the femur is placed in this socket and the wound 
is closed. 
The operation of Lorenz is simpler, less destructive, and avoids the 
destruction of the muscles surrounding the hip. He advocates an ante- 
rior incision which exposes the joint, and the capsule is opened by a 
T-shaped incision. The head is made smaller if need be, the acetabu- 
lum is scraped out, and reposition is accomplished. 
Front view of a double dis- 
location of moderate se- 
verity, showing the charac- 
teristic attitude in standing, 
as well as the broadening of 
the perineum. 
Bradford calls attention to the importance of the division of the Y-ligament. 
The limb is put up in a position of slight abduction. The operation has been but 
little done in America by the method of Lorenz. Lorenz himself operates with 
much rapidity, and the operation only lasts a few minutes. He reports 100 cases 
1 Revue d’ Orthopedic, Sept., 1894. 644 
ORTHOPEDIC SURGERY. 
without a death operated on by his method.1 Broca2 reports 25 cases operated on 
by Hoffa’s method; 5 died (4 of sepsis), there was 1 case of relapse, 1 recovered 
with ankylosis, but of the cases where the results were obtainable they were 
excellent; 2 walked without a limp. Of 177 cases by German surgeons, there 
were 6 deaths, which may have been due directly to the operation, making a mor- 
tality of 3.3 per cent. The German surgeons describe a large proportion of cures 
from their operations. Hoffa’s operation is the one which has been done in America, 
and it must be admitted that American surgeons, as a rule, have not been able to 
procure such results as are reported in Germany; and it is not an unfair statement 
to say that, so far as the Hoffa operation is concerned, it is regarded here as being 
of questionable utility in most cases. With regard to the Lorenz operation, Amer- 
ican surgeons have had but little experience with it, and have regarded it chiefly 
as a modification of the Hoffa technique. It is, however, a very different opera- 
tion, and it is likely that it will have a more brilliant future than the Hoffa 
method. 
With regard to operation in general, it may be said that the reposi- 
tion of the head is easy, although it is sometimes hard at first to recog- 
nize the original acetabulum. The difficulty comes in retaining the head 
of the femur in the socket. After any operation the wound should be 
closed and perfect quiet insisted upon for about four weeks, when passive 
motion should be begun. It is necessary that the joint should be pro- 
tected for some months by some splint or appliance which prevents the 
weight from coming upon the hip-joint. The whole question of opera- 
tion must at present be considered as being sub judice. From the Amer- 
ican standpoint the Hoffa operation has been largely a failure. The 
Lorenz operation has been hardly known, and any operation at present 
must be regarded to a certain extent as a surgical experiment. Treat- 
ment bv traction and other methods has not yielded good results, yet 
untreated cases are likely to grow worse as they grow older. Conse- 
quently, a certain number of people prefer to take the chances of an 
operation which may yield an excellent result or, on the other hand, 
which may result in failure. 
Dislocation of the hip may occur during the acute arthritis of infants from sepa- 
ration of the epiphysis of the femur. In later years this condition may simulate 
congenital dislocation of the hip most closely. Dislocation of the hip may also 
occur later after severe infantile paralysis where the muscles become relaxed and 
allow the head of the femur to slip out of the acetabulum. 
The treatment in either of these cases does not differ essentially from that 
of congenital dislocation. 
Coxa Vara.3 
Coxa vara, or incurvation of the neck of the femur, is an affection 
to which attention has been directed of late. It is rhachitic in origin, 
and affects most often adolescents, although it probably is more of a 
factor in children with rickets than has been supposed. 
Pain, limping, shortening of the affected limb, and elevation of the 
trochanter are all present: eversion of the limb is noted. It is to be 
distinguished chiefly from congenital dislocation of the hip-joint and 
from hip disease, which it simulates, by pain and tenderness. 
Rest and protection to the joint are followed by good results in the 
early stages, but osteotomy may be necessary. 
1 Lorenz, Angeb. Huftverrenkungen, Wien, 1895. 2 Revue d’ Orthopedie, 'Nov. 1, 1895. 
3 Tram. Am. Orth. Asstn., vol. vii. p. 270, and quotations in Tubby’s Orthopaedic Sur- 
gery, London, 1896, p. 263. Also recent paper by Alexander Ogston. BOW-LEGS. 
645 
Bow-legs. 
The condition known as bow-legs, or genu varum, is most often 
the result of rickets and occurs chiefly in young children. Bow-legs 
may also result from ostitis deformans in elderly people. It is cha- 
racterized by an outward bowing of the bones of the leg, which at times 
is associated with or replaced by a forward bending of the tibia and 
fibula, and one speaks of the latter condition as anterior bow-legs. 
Bow-legs occurs for the most part in children between one and four years of 
age, but as a rule it is not noticed until the children begin to walk. It is not in 
all cases—perhaps not in most cases—caused, as has been so commonly supposed, 
by allowing the child to walk too soon, but rather it is the result of a tonic con- 
traction of the muscles which pull the softened bones out of the straight line. 
The weight of the child in walking when it comes upon the softened bones tends, 
of course, to increase the curve. Although it is associated in most cases with a 
certain degree of rickets, bow-legs may be found at times in children where the 
diagnostic signs of rickets are not present; yet it must be assumed that the 
softening of the bones has existed if this distortion is to be found. It occurs not 
infrequently in children under six months of age, and between six months and a 
year and a half many cases develop, It is a more common deformity than knock- 
knee. In 9050 cases of surgical disease in children which were analyzed there 
were 570 cases of bow-legs and only 370 cases of knock-knee. Both knock-knee 
and bow-legs affect boys more frequently than girls. 
The condition of anterior bow-legs is characterized by a bowing for- 
ward of the tibia and fibula. This 
is generally most prominent at the 
junction of the lower and middle 
thirds of the leg. It occurs, as a rule, 
Fig. 296. 
Fig. 295. 
in the cases were severe rickets is present, and is generally associated 
with some outward bowing of the leg or with knock-knee. 
Symptoms.—Children with bow-legs stand with the feet wide apart, 
even in the milder cases. In walking they sway from side to side with a 
rolling gait, balancing themselves over each leg as it rests in turn on 
the ground. The fact that they stand with the feet apart is probably 
Anterior bow-legs. 
Bow-legs affecting both tibia and femur. 646 
ORTHOPEDIC SURGERY. 
due to muscular weakness, and because the centre of support is removed 
so far outside of the centre of gravity. The bowing is of two types 
(Figs. 295, 296). In one it affects the femur and the tibia; in the 
other it affects the latter bone alone. In the former case the children 
stand forming a well-defined oval with their bowed legs. Where the 
tibia alone is affected the general symmetry of the curve is less. The 
easiest method to find out whether the curve involves the femur to any 
extent is to cross one leg of the child over the other, placing the inner 
sides of the knees in contact when the child lies down. In cases where 
the curvature is principally in the tibia the thighs will come closely 
together. In extreme cases of bow-legs the knee-joint may be involved, 
but in general this is not a factor to be considered. The bones of 
children in the active stage of bow-legs are by many thought to possess a 
certain springiness, which is often demonstrated to students by bending 
the legs with the hands and watching the bones spring back, when a 
distinct yielding is felt. It is probable that this is due to the elasticity 
of the muscles themselves, rather than to any springiness of the bone. 
The bones of rhachitic children are plastic rather than elastic. 
It is important that a record of cases of bow-legs and of knock-knee should be 
kept for comparison. This is easily done by making the children sit or lie down 
on a piece of brown paper with the feet together and the toes pointing upward. 
With a pencil held perpendicularly to the paper the outline of the legs and feet is 
traced. These tracings can be inked and kept for reference. 
Diagnosis.—The diagnosis presents no difficulty, and the only 
affection which bow-legs resembles is double congenital dislocation of 
the hip, the gait of which it simulates very closely. It should be men- 
tioned that the two affections may possibly coexist. 
Prognosis.—The prognosis of anterior bow-legs is in general poor, 
unless operation is undertaken. It is not likely that the children will 
outgrow the deformity, nor is it easy, as a rule, to control it by mechan- 
ical treatment. The outward bowing of the leg, ordinary bow-legs, is a 
more easily remedied affection, and in young children, except in severe 
cases, the prognosis under mechanical treatment is almost always favor- 
able. Even without treatment certain cases recover and others do not, 
but which cases are the favorable ones no surgeon can tell in advance. 
It has been supposed by some writers that in general it is probable that 
where the curve is gradual and involves both femur and tibia, spon- 
taneous recovery is more likely to occur than when confined to the 
tibia alone. In some interesting observations made by Whitman, who 
observed 2000 people walking the streets of Boston, the prevalence of 
bow-legs in the adult was shown by the fact that he saw 400 of them 
bow-legged, while 32 had knock-knee. It is quite evident from this 
that all cases of bow-legs are not outgrown. 
Treatment.—The treatment may be expectant, mechanical, or 
operative. It is hard to state definitely where the need of mechanical 
treatment begins in bow-legs. 
Expectant Treatment.—In certain cases it is easy to see that the 
mechanical conditions are so bad that some support is imperatively 
necessary, but except in cases where the curvature is quite marked it is 
safe to allow the child to continue under observation, taking tracings 
every three months and massaging the legs and treating the general BOW-LEGS. 
647 
condition of rickets; but this is only proper where one can depend upon 
the co-operation of the parents. 
Cases where the children “ toe in,” walk with a rolling gait and stand with the 
feet wide apart, are not suitable cases for expectant treatment. Massage and 
manipulation should be performed at home once or twice a day during either the 
expectant or mechanical treatment. The parents should be instructed" to rub the 
legs and to attempt to bend them into a correct position, not using enough force to 
make the child cry. 
Mechanical treatment is suitable for all children under four years 
of age; sometimes after this. Although in children it is difficult 
after the age of four to accomplish 
much by braces, it must be said 
that remarkable results can be 
obtained, even in the case of much 
older children, by persistent con- 
finement to bed and by the long- 
continued use of some splint or 
bandage which tends to pull the 
knees together. Mechanical treat- 
ment is easily applied by a simple 
steel upright attached to the body 
which runs to the top of the inside 
of the thigh and terminates in an 
arm curving around and upward. 
To this upright the legs are firmly 
pulled by means of leather pads, 
which act upon the most prominent 
part of the deformity. 
Fig. 297. 
Eversion of the feet in walking is 
secured by the arms in which these braces 
terminate. By buckling the ends of these 
arms behind the back the feet can be turned out to any extent. In cases where the 
curvature is confined entirely to the tibia the braces can be terminated at the knee 
in a pad. Various forms of elastic spring braces and other forms of steel uprights 
are used, but the simple one described is in general satisfactory. Improvement 
should be noticed within a few months after the application of the braces. When 
mechanical treatment fails operative measures should be adopted. 
Apparatus for bow-legs (by permission of the 
managers of the Children’s Hospital, Boston). 
The mechanical treatment of anterior bow-legs is unsatisfactory. 
Operative measures should not be undertaken with children with 
bow-legs under the age of three years, and preferably not younger than 
four, as in these cases the bones are not sufficiently hardened. In most 
cases a simple fracture of the tibia and fibula is sufficient to correct the 
line of the leg even where a mild curvature of the femur exists. 
Osteoclasis and osteotomy are the measures adopted for the cor- 
rection of bow-legs. Osteoclasis may be done by the hands by very 
strong surgeons, but the fracture is not so accurately located as that 
done by some apparatus. The osteoclast of Rizzoli consists of a bar 
and two padded rings sliding upon it. Between the padded rings a 
padded plate is screwed down, fracturing the bone at the point of appli- 
cation. It is a simple and satisfactory apparatus for the operation. In 
fracturing a leg the force of the osteoclast should be so adjusted that it 
will not break off either at the upper or lower epiphyses of the tibiae, which 
are not firmly united at so early an age. 648 
ORTHOPEDIC SURGERY. 
With as little manipulation as possible the bone should be set straight and the 
leg should be done up in a plaster-ot-Paris bandage and treated as a simple frac- 
ture. The results of osteoclasis, properly done, are almost uniformly satisfactory. 
Osteoclasis is suitable for cases of anterior bow-legs of a mild grade in chil- 
dren over four. The bone is broken, as in ordinary bow-legs, at the seat of the great- 
est curvature, and in many cases the leg can be placed straight so far as the antero- 
posterior outline is concerned. Division of the tendo Achillis should be done after 
the bone is broken. 
Osteotomy is to be preferred to osteoclasis if the femur be curved, 
if there be a curvature of the tibia in two planes, if anterior bow-legs 
be very marked, or if the bones be very hard. Osteotomy consists in 
chiselling the bone nearly through and completing the fracture manually. 
Theoretically, it is not a more dangerous operation than osteoclasis, but 
bad results due to sepsis occur from time to time. In the worst cases 
it may be desirable to remove a wedge-shaped, piece of bone. In severe 
cases of anterior bow-legs the tibia may be divided from behind, and 
in this way the removal of a wedge is made unnecessary. In such cases 
the tendo Achilles will probably have to be divided to bring the foot 
straight. After osteotomy the leg should be dressed antiseptically and 
treated as a compound fracture. 
Knock-knee. 
Knock-knee is a condition represented by an inward prominence of 
the knee, caused most often by overgrowth of the internal condyle of 
the femur. This results generally from rickets, but inward deformity 
of the knee may occur after fractures, in tubercular diseases of the knee, 
and sometimes in advanced cases of infantile paralysis affecting the 
muscles of the leg. In the latter instance it is generally associated with 
some flexion of the knee. The common rhachitic form of knock-knee, 
which will be the only one considered here, occurs most often in children 
between two and four years old. It is less common than bow-legs. In 
most cases it is probably caused by the attitude assumed by these chil- 
dren in standing. Inasmuch as their muscles are weak, they support 
themselves by standing with the legs apart and the feet everted, being 
the position in which the least muscular activity is required. This 
brings more weight to bear upon the external than on the internal con- 
dyles, and tends to cause the atrophy of the external condyles of the 
femur and the overgrowth of the internal.1 Bending of the shaft of 
the bones above and below the knee-joint may also occur and increase 
the deformity, but this is less often the case than in bow-legs. Flat-foot 
in nearly all cases coexists, probably most often as a result of the same 
cause—muscular weakness. In severe cases, where the feet are widely 
separated, an inversion of the front part of the feet is noticed as they 
reach toward the median line for support. In severe cases the tibia 
and fibula rotate outward in the long axis of the leg. 
Symptoms.—Children with knock-knee walk with a peculiar sway- 
ing gait. If they were to walk in the ordinary way, with each foot 
straight ahead, the prominent knees would knock against each other 
and progress would be impossible. Consequently, they rotate the legs 
either outward or inward in order to diminish the prominence of the 
1 Arbutlmot Lane, Guy's Ilosp. Hep., xxviii. KNOCK-KNEE. 
649 
inner aspect of the knee, and thus “ toeing out ” or “ toeing in ” is 
often the first symptom to call attention to the trouble in the slighter 
grades. Pain is absent, but children with knock-knee are clumsy and 
fall easily. On examination one finds that the deformity, however 
prominent, disappears on flexing the knee. This is because the condi- 
tion which causes the deformity is the greater length of the internal 
condyle of the femur. Examination of the lower end of the femur 
when the leg is flexed shows the prominence very plainly. Laxity of 
the lateral ligaments is often noticed, as a result of which the deformity 
is more noticeable when the patient stands and weight comes upon the 
knees. 
Diagnosis.—The diagnosis presents no difficulty in marked cases. 
In mild cases, where flat-foot is marked, the attention may be given 
wholly to the latter condition, and the more serious condition of knock- 
knee may be quite overlooked. 
Prognosis.—The prognosis is not so good as in bow-legs. It is 
unlikely that any marked degree of the deformity can be outgrown. 
On the contrary, the mechanical conditions are 
such that the deformity is much more likely to 
increase than to diminish. 
Treatment.—The treatment may be expect- 
ant, mechanical, or operative. 
Expectant treatment is only suitable in mild 
cases, where the children remain under observa- 
tion and they have the benefit of continual mas- 
sage and manipulation. Frequent tracings of 
the legs should be taken. It is important that 
the conditions which favor knock-knee should be 
prevented as much as possible, and for this reason 
it is advisable that the flat foot should be corrected 
by elevating the arch of the foot in all cases which 
show marked flat-foot. This may be regarded as 
a remedial measure which is likely to affect knock- 
knee. The general treatment of rickets in all cases 
where the disease is active is not, of course, to be 
forgotten. 
Mechanical treatment is suitable for all cases in 
children under four years of age. It should be 
begun as soon as the knock-knee becomes at all 
marked, even if the child is just beginning to 
walk. The simplest appliance consists of an up- 
right steel which is fastened to the shoe below and 
runs the length of the leg, to terminate above in 
a band which grasps the pelvis. A leather pad 
runs from this upright around the inside of the 
knee to pull it outward. A posterior arm from this 
upright, embracing the back of the leg near the 
knee, is an assistance to prevent flexion of the 
knee. The objection to the apparatus is that the knee is likely to bend, 
and that with the bending of the knee the deformity diminishes; con- 
sequently, to obtain the best results the knee must be kept straight. 
Fig. 298. 
Simplest form of brace for 
knock-knee. 650 
ORTHOPEDIC SURGERY. 
Long-continued confinement to bed with a cushion between the knees and 
the feet bandaged together is often, in older cases, capable of producing 
satisfactory results. Elastic traction and various forms of splints have 
been devised, the principle of all of which is that described above. 
Operative treatment is applicable to all cases of knock-knee of more 
than the mildest grade in children over four years of age. It is not 
advisable to undertake it at an earlier period. 
Osteoclasis is not so satisfactory as osteotomy in 
knock-knee, because the fracture should be lo- 
cated as near the joint as possible, and except 
with the most elaborate osteoclasts this is prac- 
tically impossible. 
The operation most often preferred is the 
osteotomy of Macewen. An osteotome is 
used. It should be about half an inch in 
breadth, and the blade should be marked to 
show how deeply the edge has penetrated. A 
common wooden mallet is the most suitable in- 
strument to use. The osteotome is driven into 
the femur at its inner aspect half an inch above 
the adductor tubercle of the femur. No in- 
cision in the skin is necessary unless it is pre- 
ferred. By successive light blows of the mal- 
let the osteotome cuts through nearly the whole 
thickness of the bone, which is then fractured 
manually and the leg is placed straight. Un- 
necessary manipulation is to be avoided. The 
straightened leg is placed in a plaster-of-Paris 
bandage and treated as a compound fracture. 
Hemorrhage is generally slight, and accidents may be avoided by grasp- 
ing the osteotome so firmly that it cannot slip, and by cutting the pos- 
terior edge of the bone with the chisel pointed forward. Ogston’s 
operation, which is perhaps the one best suited to very severe cases, 
aims at loosening the internal condyle of the femur with a chisel or 
saw cutting from above the adductor tubercle to the intercondyloid 
notch. Hahn advocates the performance of osteotomy on the outer as 
well as on the inner side of the femur, but this view has not met with 
general acceptance. 
The various operations for the correction of knock-knee may be 
seen by a glance at the diagram (Fig. 299). 
Fig. 299. 
1, Mayer, Billroth, Schede; 
2, Annandale; 3, Ogston, 
Reeves, Chiene; 4, Macewen; 
5, Taylor. 
Congenital club-foot, or talipes equino-varus, is the term applied 
to a condition of the foot in which the sole is inverted, the front part of 
the foot is displaced inward and upward, and the heel elevated. 
The deformity has its origin probably in an arrest of development of the feet 
of the foetus in utero, resulting in the delayed rotation of the legs and feet. Dur- 
ing the early part of intra-uterine life the feet lie in the position of equino-varus,1 
Congenital Club-foot. 
1 Berg. Archives of Med., N. Y., Dec. 1, 1882; Parker and Shattuck, Br. Med. Journ., 
1886, ii. 10. CONGENITAL CLUB-FOOT. 
651 
and a persistence of this foetal condition is likely to result in club-foot. The de- 
layed rotation of the feet may be due to various causes, such as mechanical 
obstruction or some abnormal condition of the nervous or circulatory system of 
either mother or child. If this view of the origin of the deformity is accepted, it 
brings it into the same class with spina bifida and other similar malformations with 
which it frequently coexists. Heredity is an undoubted factor in the production 
of club-foot, and much influence has been attributed to maternal impressions as a 
causative factor, although probably in most cases impressions are not the cause of 
the deformity. Abnormal development in the uterus, the paralysis of certain 
muscles, and primary bony changes have been advocated as the cause of club-foot, 
but .the view that it originates in retarded development is the one generally 
accepted. 
Pathology.—The deformity is a dislocation inward of the anterior 
part of the foot which occurs at the medio-tarsal articulation. All the 
tissues, muscle, skin, fasciae, and the bones in older cases, are affected by 
the malposition. The alteration in shape of the bones is of the most 
significance, because it offers the greatest obstacle to reduction. The os 
calcis becomes more vertical than horizontal, and its anterior articulating 
Fig. 300. 
Normal foot (right) (Burrell). 
facet is oblique to the axis of the bone. In the severest cases the inner 
side may be concave. The astragalus tips forward on a transverse axis, 
so that only the posterior part of the articular surface is in contact with 
the tibia, the anterior part of this surface making a prominence under 
the skin; the head and neck twist inward; the scaphoid is carried 
inward, and with it the cuneiform bones and metatarsals attached to 
them. This results in a broadening of the anterior part of the foot. 652 
ORTHOPEDIC SURGERY. 
The ligaments are contracted on the concave side of the foot and 
stretched on the other. The muscles atrophy from lack of proper use, 
and bony growth is likely to be retarded. The muscular reactions are 
normal. The tendons are somewhat displaced, but no other abnormality is 
present. Synovial bursse may form on the outer edge and back of the foot. 
The symptoms and diagnosis of club-foot are the direct outcome 
of the anatomical conditions. The patients walk upon the outside of 
the feet, and in walking lift the feet high, rolling one over the other in 
Fig. 301. 
a manner which is very noticeable. The deformity is a most unsightly 
one. Reposition of the foot by manual pressure is impossible in any 
but the slightest cases. 
Talipes equino-varus resulting from infantile paralysis may present 
appearances closely resembling those of congenital club-foot. The 
deformity is, however, more amenable to treatment and more easily 
corrected. 
Prognosis.—Without treatment there is no hope of cure or im- 
provement in the deformity. The foot tends all the time to become 
more fixed in its vicious position, and the bony changes which result 
serve to lock it in place. With treatment begun during childhood the 
prospect of a cure is always good if the intelligent co-operation of the 
parents can be obtained. Even in adults excellent results may be ob- 
tained by operative measures. 
Treatment.—The treatment of club-foot consists simply in recti- 
Talipes equino-varus (left) (Burrell). CONGENITAL CLUB-FOOT. 
653 
fying the deformity by the mildest measure that will serve, and in keep- 
ing the foot in the correct position. 
The measures to be employed in a young infant must necessarily differ widely 
from those in an adult, but whatever means of correction are adopted the deform- 
ity should be over-corrected, however destructive may be the means required to 
do this. A half-cure in club-foot amounts to nothing. The various methods of 
correction will be considered in the order of their severity: 
(1) Manipulation ; 
(2) Plaster-of-Paris bandages; 
(3) Mechanical correction; 
(4) Tenotomy; 
(5) The use of extreme force; 
(6) Open incision; 
(7) Bony resection. 
The inherent tendency of all cases of club-foot to relapse in the years follow- 
ing correction cannot be too strongly insisted upon. 
(1) Manipulation of the foot should be begun as early as possible, 
however young the infant may be. Any mother can be instructed to 
replace the foot in the normal position every time that she changes the 
Fig. 302. 
Mechanical correction of club-foot. 
diaper. The outer border of the foot should be pressed upward and 
outward, thus correcting in the same movement the varus and the equi- 
nus elements of the deformity. Complete cures of bad club-foot may 
result from this measure alone. 
(2) Plaster-of-Par is bandages, carefully applied, in the ease of young 
infants may produce improvement or cure. A period of manipulation 
should precede their use, even in the youngest infants, to render the foot 
more flexible. 
The bandage should be applied to the foot placed in the most correct position 
possible, and held in this position while the plaster is hardening. Such bandages, 
properly applied, stretch the contracted structures, and at the removal of the 
plaster a more correct position can he secured in the application of the second one. 
It is probable that these bandages accomplish their work in about three days, and 
that the most rapid progress can be made by changing them at this short interval. 
Plaster of Paris is also applied to hold the foot in a correct position after ope- 
ration in most cases. 
(3) Correction of the deformity by mechanical apparatus alone is pos- 654 
ORTHOPEDIC SURGERY. 
sible in mild cases in children, and the need of some mechanical reten- 
tion-appliance is necessary for correction in every case, no matter what 
means may have been employed (Fig. 302). The Taylor club-foot shoe 
is the most satisfactory appliance, both as a correction and retention shoe. 
It consists of a steel sole-plate to which the foot is strapped. From this 
sole-plate arises an upright which reaches to just below the knee. The 
sole-plate is adjusted to the foot in the deformed position, and then by 
the use of the upright as a lever the foot is brought up and the outer 
border raised by bringing the upright into its place at the side of the 
leg. This can be worn inside of the boot, and when weight is borne 
upon the foot the efficiency of the apparatus is increased (Fig. 303). 
A roughly-made apparatus for the reduction and correction of club-foot con- 
sists in the “snow-shoe” appliance, which is merely a shingle fastened to the heel 
of the foot by sticking-plaster strips 
running down each side of the leg. 
The front part of this projects out, so 
that traction may be made by a plaster 
extending to the leg. 
Shaffer believes in the use of an 
apparatus exerting intermittent force, 
but such intermittent force is necessarily 
slow in producing improvement. The 
use of elastic traction is, as a rule, un- 
satisfactory and cumbersome, and the 
complicated apparatus at the instru- 
ment-shops has no place in the modern 
treatment of club-foot. 
So strong is the tendency of these 
children to walk with the toes inverted 
that it is advisable as soon as they begin 
to walk to carry an upright upward as 
far as the pelvis, where a rigid horizontal 
arm may be added, which, strapped 
around the waist, makes inversion of 
the foot impossible. The tendency to 
“ toe in” persists after correction of the 
deformity (Fig. 303). 
Whether or not mechanical correc- 
tion shall be persisted in or shall give 
way to operative measures is in the case 
of most young children a question of 
expediency. Mechanical treatment is 
slow. It requires constant and intelli- 
gent care on the part of the surgeon 
and parent, but, if persisted in, in mild 
cases it yields most satisfactory results. 
It is not, as a rule, suitable to cases 
where much bony deformity is present. 
(4) Tenotomy is the mildest of 
the operative measures, and is 
justifiable in the treatment of any 
ease of club-foot where it is desirable to save time or where attempts at 
mechanical correction are unsatisfactory. In older cases and in relapsed 
cases it is not, as a rule, a sufficient measure. The tendo Achillis and the 
plantar fascia are most often the structures to be divided. In severer 
cases the astragalo-scaphoid and calcaneo-cuboid ligaments should also 
be divided subcutaneously. 
After division the foot should be at once replaced in an over-cor- 
Fig. 303. 
Club-foot shoe with upright to secure eversion ~ 
(Taylor). CONGENITAL CLUB-FOOT. 
655 
rected position. The fear that non-union of the tendons may occur if 
this is done has no foundation. Cases which are allowed to relapse after 
tenotomy are more resistant than if they had never been operated upon. 
The foot should be held in the correct position by some stiff’ bandage 
or by a Taylor club-foot shoe. Any appliance is efficient which holds 
the foot in a slightly over-corrected position. After three weeks walking 
may be resumed if tenderness has disappeared at the site of the operation. 
(5) The use of extreme force under ether after tenotomy is often 
necessary in order to tear resistant ligaments which are not within reach 
of the knife. This force may be applied by the hands, by Thomas’s 
wrench, or by Bradford’s apparatus, which works with a sole-plate and 
long lever. It is surprising how great an amount of force can be safely 
used in these cases. Whatever apparatus is used is only intended to 
supplement the force exerted by the hands, and by the intelligent use 
of extreme force the performance of operations upon bone has been 
largely done away with. 
(6) Open incision consists simply in dividing all the resistant struc- 
tures in the sole of the foot. It is spoken of as Phelps’s operation. 
The incision need not necessarily be transverse, but can be carried 
obliquely forward near the inner border of the foot, through which 
incision all resistant structures can be divided. If the transverse cut- 
ting is done fairly well forward, the bleeding is often insignificant. The 
incision described by Phelps runs from the inner malleolus to the inner 
side of the neck of the astragalus. Through this incision may be cut 
all soft structures as they offer resistance. 
The operation should be performed in cases where reposition is not possible 
after tenotomy. In the severest grade of cases, where the bony changes which 
have been described are present, some further measure will be necessary after open 
incision which only divides the soft parts. These measures may be extreme force 
(as spoken of above) or some operation upon bone. 
(7) Resection of bone occupies of late years a steadily less important 
place in the treatment of club-foot. The performance of needlessly muti- 
lating and extensive bony resections will not be considered here. In 
Young’s Orthopaedic Surgery can be found a list of sixteen different ope- 
rations upon the bones of the foot for this deformity. The two operations 
to be considered in this article will be osteotomy of the astragalus and 
os calcis and excision of the astragalus. Where marked obliquity of the 
neck of the astragalus exists, and the front part of the os calcis is curved 
inward, it is not likely that division of the soft parts will rectify the 
deformity. In these cases a wedge-shaped piece should be removed from 
the outer side of the os calcis. If resistance persists after this, an 
osteotome can be inserted into the neck of the astragalus, which can be 
cut through or a wedge-shaped piece of bone may be removed from it. 
Correction will then be easy. 
Excision of the astragalus alone yields satisfactory results in nearly all cases, 
but, as pointed out by Bradford, a certain amount of inward deviation of the front 
part of the foot persists, which is not the case after osteotomy of the os calcis. 
The removal of so important a bone as the astragalus is to a certain extent a 
mutilating operation, which seems unnecessary if osteotomy of the os calcis will 
answer as well. The removal of a large wedge of bone from the tarsus is con- 
sidered unnecessary. 
The treatment of club-foot is, in a word, as follows: The deformity 656 
ORTHOPEDIC SURGERY. 
should be corrected by manipulation and retention by a stiff bandage in 
infants. Later, tenotomy or open incision may be necessary if mechan- 
ical treatment has failed or has not been undertaken. After the per- 
formance of tenotomy or open incision correction by instrumental force 
may be necessary. If rectification cannot be obtained in this way, 
osteotomy of the os calcis and astragalus must be performed.1 
The mildest measure that will over-correct the deformity is the best, 
but over-correction is essential, no matter what means are necessary to 
produce it. Any treatment is incomplete which does not provide against 
the occurrence of a relapse. This can only be followed out by having 
the patient wear an efficient retention shoe, such as the Taylor shoe, for 
some two or three years at least after operation. Whatever apparatus 
is worn should be discontinued gradually and carefully. 
Club-hand. 
Club-hand is the name applied to a rare congenital condition which 
is in a measure analogous to congeni- 
tal club-foot, and which may occur in 
connection with it. The deformity 
consists in a deviation of the hand 
from the line of the forearm. This 
deviation is almost always toward 
the flexor surface of the arm, and the 
case is spoken of as dorsal club-hand 
when the deformity is toward the 
extensor surface of the forearm, and 
as palmar club-hand when the devi- 
ation is toward the flexor surface. 
It is also spoken of as radial club- 
hand when the deviation is inward, 
and as ulnar club-hand when the 
deviation is outward at the wrist. 
Radio-palmar club-hand is the most 
frequent form.2 
Fig. 304. 
A certain amount of deformity of the 
bones is generally present. The carpus 
may be incompletely developed or it 
may be almost entirely wanting. In the 
radial forms the radius is often wholly or 
partly wanting, and the lower end of the 
ulna may be enlarged to articulate with 
the carpus. 
A deformity simulating club-hand may 
result from intra-uterine fractures or cic- 
atrices, also from cerebral irritation. The 
cause assigned for the occurrence of club- 
hand same as that given to account 
for the presence of congenital deformities 
in general. 
The hand is not held so rigidly as is the case in club-foot, and it can be moved 
through a certain arc. 
Club-hand. 
The diagnosis is evident from inspection. 
1 Young, Med. News, May 12, 1888. 
2 Orthopaedic Trans., vol. vi. p. 211. AFFECTIONS OF THE ARCH OF THE FOOT. 
657 
Treatment.—In the milder cases tenotomy of the resistant and con- 
tracted muscles or the stretching of them by manipulation or splints 
may be efficient. In dividing the tendons it is better to lengthen them 
by open incision than to divide them subcutaneously, as the possibility 
of non-union is greater here than in tenotomy in general. Where the 
radius is deficient and the deformity severe amputation may be advisable. 
R. H. Sayre has resected the ulna and part of the carpus in a case of the 
radial variety, and has obtained a fairly useful arm (Fig. 304). Each 
case, of course, must be treated on its merits, and the policy to be pur- 
sued would depend largely upon the deficiency of the bones. 
Affections of the Arch of the Foot. 
The abnormal conditions pertaining to the arch of the foot will be 
considered under three headings. These divisions are—(1) pronated 
foot, (2) flat-foot, (3) contracted foot. The ma- 
jority of cases showing these conditions have for- 
merly been grouped under the title of “ flat-foot,” 
which will here be restricted to signify a definite 
condition. 
(1) Pronated Foot.—The name “pronated foot” 
will be applied to an abnormal condition where in 
standing the foot rolls out and the inner malleolus 
tends to become more prominent than it should. 
The line of weight, instead of passing through the 
inner part of the metatarsus, falls, as a rule, inside 
of the foot. A certain amount of abduction of the 
front part of the foot is necessarily anatomically 
associated with pronation. This condition is most 
easily noticed if the patient stands with the foot 
upon the ground, bearing little or no weight. If 
the body-weight is thrown upon the leg, it will be 
noticed that the inner malleolus becomes more 
prominent, while the relation of the foot to the leg 
changes, and, instead of continuing in the line of 
the leg, as it should, the foot proper tends to roll 
outside of it. The condition can be more easily 
appreciated from an illustration than from a verbal 
description (Fig. 305). A long-exposure plate was 
used, and the patient stood without weight upon 
the leg and with weight upon the leg. The two 
separate photographs are therefore shown upon the 
plate—one of the normal position and the other of the abnormal or 
pronated position. 
Fig. 305. 
The leg and foot without 
and with the superim- 
posed weight of the 
body. 
Pronated foot has not been recognized as a separate pathological condition, 
because in most instances it has been regarded, as it most often is, as an early 
stage of flat-foot, but with the more extended study of flat-foot it becomes evident 
that many cases of painful affection of the foot due to abnormality of the arch of 
the foot are not shown by any demonstrable alteration of the arch. These cases 
must be classified as pronated foot. 
The study of the arch of the foot and its variations has been made for the 
most part by a study of the imprint of the foot as shown upon a piece of smoked 658 
ORTHOPEDIC SURUPRY. 
cardboard or by placing the wet sole upon a piece of paper (Figs. 306-308). This 
method of studying the arch of the foot does not in any way show the existence 
of pronated foot, where the imprint may be perfectly normal. For example, Fig. 
306 shows the case of a woman twenty-seven years old. Pain had lasted for two 
Fig. 306. 
Fig. 307. 
Flat-foot. 
Normal foot. 
Fig. 308. 
Imprints of the palmar surface of flat and pronated feet. 
Contracted foot. 
years in connection with standing, and had extended to the knee and hip. It had 
been so severe that there was much swelling of the feet at times. A smoked trac- 
ing of the foot showed a perfectly normal imprint. The photograph showed a 
marked degree of pronation of the foot. Here, then, is a case of disabling painful 
difficulty in the feet, accompanied by a very marked degree of pronation at the 
ankle-joint, which was not shown by a smoked tracing. 
(2) Flat-foot should be restricted to those cases where a tracing of 
the foot, taken as described, shows a distinct breaking down of the arch. 
Pronation of the foot to some degree must be present where the arch is 
lowered, for obvious mechanical reasons. Flat-foot is not necessarily a 
disabling affection. It may vary in degree from a slight flattening of 
the normal arch to a condition where the whole bottom of the foot 
touches the ground. 
The foot at birth is not flat, as has been stated in most books, but the 
arch is well formed, and in reality the scaphoid lies from 1.5 to 2 cm. 
above the plane of the heel. This fact has been demonstrated by Dane.1 
For the first two or three years of life the fact that the imprint of a 
child’s foot is like that of an adult flat-foot does not necessarily mean 
that the arch of the child’s foot has broken down, although children 
1 Rot eh’s Pediatrics. 659 
AFFECTIONS OF THE ARCH OF THE FOOT. 
may have flat feet. In thin children the imprint of the foot at this age 
is not that of a flat foot, but of a normally developed arch. At four or 
live years of age the arch should form, and the tracing should then be 
that of the normal adult type. 
The CAUSES of pronated and of flat-foot will be considered together. 
In general terms it may be said that the deformity is caused by a dispro- 
Fig. 309. 
Foot-print in a case of pronation: the two outlines inside show the position of the inner border 
of the foot with and without weight-bearing. 
portion between the weight to be borne and the muscular power which 
bears it. The immediate causes of deformity of the arch of the foot in 
the order of their approximate importance are as follows : 
(1) Bad boots, which cramp the forward part of the foot, displace the 
great toe outward, and fail to support the arch. The muscles intended 
to support the arch arc disabled and do not contribute proper muscular 
support. The shape of modern children’s boots tends to throw the great 
toe outward and to favor the occurrence of deformity at this early age. 
Fig. 310 shows the typical relation of a woman’s ordinary boot to the 
foot of the individual wearing it. It is obvious that such relation is 
opposed to proper muscular support and proper weight-bearing. 660 
ORTHOPJEDIC S URGER Y. 
(2) Weakness or inefficiency of the muscles resulting from— 
(а) Long standing, especially on hard-wood floors; 
(б) Rapid growth ; 
(c) Poor health and debility ; 
(d) Convalescence from acute illnesses; 
(e) Rapid gain of weight; 
(/) Accident, injury, or disuse of limb. 
(3) Excessive weight-bearing, as in the case of professional “ strong ” 
men and “jumpers.” 
(4) A shortened condition of the gastrocnemius muscle. 
(5) Rickets, for the most part to be observed in young children. 
(6) Infantile paralysis. 
(7) Direct traumatism. 
(8) Locomotor ataxia and similar organic nervous diseases. 
Pronated foot and flat-foot are associated often with rheumatoid arthritis and 
neurasthenia. There is a type of intractable flat-foot seen in young adults, accom- 
panied by marked muscular atrophy, where treatment is of little avail. Its eti- 
ology is most obscure. 
Pathology.—The pathological changes in pronated foot show noth- 
ing more than the results of long-continued strain of the tissues at the 
outer side of the foot and contraction of the inside. 
In the severest cases of flat-foot the pathological 
changes are only those which result from the pro- 
longed maintenance of the vicious position. In 
the beginning the changes are only an exaggeration 
of those occurring in normal abduction, or, if 
abduction of the forward part of the foot becomes 
prominent, a general rotation inward of all the 
bones on an antero-posterior axis takes place. 
Certain ligaments are stretched, while others are 
contracted; new articular facets develop where 
the changed relations of the bones bring new parts 
into apposition; and ultimately the bones may 
change in shape under the new conditions, but 
there is no characteristic primary pathological 
change. The inner border of the foot may become 
convex, and in the severest cases the scaphoid is 
almost completely dislocated outward. Even the 
surface of the sole may become convex in the 
severest cases. 
Symptoms.—The symptoms of pronated foot 
and of flat-foot are the same. At the onset the 
pain and discomfort are more the result of the 
pronation than of the actual breaking down of 
the arch. This fact has been largely overlooked, 
and many cases have escaped treatment because 
the tracing of the foot showed a normal imprint, 
the pronation being entirely disregarded. The 
earliest symptom in pronated foot or flat-foot is 
generally to be found in weariness and discomfort in the feet on long 
standing, the feet being hot and flushed. The patient is inclined to spare 
Fig. 310. 
The relation of an average 
boot to the foot: outline of 
boot, deep shading; outline 
of foot, light shading. AFFECTIONS OF THE ARCH OF THE FOOT. 
661 
the feet, and there is often difficulty in getting the boots to fit. Boots 
which have formerly been worn with ease become uncomfortable and 
cannot be endured. Pain is the commonest symptom, but it is gener- 
ally preceded by burning and discomfort in the feet. It comes on espe- 
cially after standing. It may radiate up the leg and thigh. It is con- 
fined to no especial location, although it is most commonly referred to 
the arch of the foot. Sensitive spots are present, but they are not 
located, as has often been asserted, in any characteristic places. Sensi- 
tiveness under the os calcis the writer lias come to regard as an unfavor- 
able prognostic sign. The veins become enlarged and the feet sweat pro- 
fusely. After resting they feel stiff1 and clumsy. The symptoms in 
general are of the character described by patients as “ rheumatic.” 
Patients begin to walk with the feet everted, as in this position less 
motion at the various joints of the foot is required. They turn over on 
the inside of their boots, and the gait is clumsy and lacks elasticity. 
Swelling of the feet and legs may occur, and abduction of the forward 
part of the foot is favored. These symptoms are all likely to be caused 
by a condition of pronated foot in which the arch of the foot shows no 
actual breaking down. Other symptoms which may be present are 
backache, discomfort, and even slight synovitis of one knee, especially 
in neurasthenic patients; pain and inflammation in the metatarso-pha- 
langeal joint; and ingrowing toe-nail. In the severest cases of flat- 
foot the foot becomes rigid in the vicious position, and reposition is not 
possible except under ether. 
Diagnosis.—These symptoms, although suggestive, are not path- 
ognomonic. If the patient is made to step upon a piece of paper with 
the wet sole or upon a piece of smoked cardboard with the dry sole, it 
can be roughly estimated whether or not the arch is broken down. The 
existence of pronated foot may be detected by the eye, remembering 
that the line of the leg should pass outside of the great toe in the nor- 
mally formed foot when weight is borne upon the leg. The existence 
of pronation is so obvious, if one examine carefully for it, that it can 
hardly be overlooked. 
It is probable that more definite information as to the bearing of the arch of 
the foot will be obtained by its study through plate glass.1 The patient stands, 
hearing weight on this glass, and the observer by aid of a mirror held under it 
reflects the picture of the bottom of the foot in actual contact with the glass. 
In this way the most accurate and reliable information can be obtained. This 
method has, however, been too recently found out to warrant any definite con- 
clusions. It is impossible to say that any condition of the arch will give rise to 
pain, or that any foot, however apparently correct in its position, will not be the 
source of pain. In no affection does the amount of pain seem to have less relation 
to the physical defect. This adds much to the difficulty of diagnosis, but, as rule, 
the pain is proportionate to the pronation, and in the vast majority of cases, except 
of contracted foot, a noticeable degree of pronation will be found present in pain- 
ful conditions. 
Treatment.—Where the mechanical cause of a condition is so obvi- 
ous as in pronated foot the treatment should be particularly plain, inas- 
much as it should be directed to combating these faults of position. In 
other words, the pronation must be corrected. This may be done— 
(1) By the use of proper boots; 
(2) By raising the insides of the boots; 
1 Lovett, N. Y. Med. Journ., June 20, 1896. 662 
ORTHOPAEDIC SURGERY. 
(3) By cultivating the muscles which support the arch of the foot 
and throw it over on the outer side ; 
(4) By the use of pads, plates, and supporting apparatus. 
This treatment applies equally well to the mild cases ot flat-foot as 
well as to those where no breaking down of the arch exists. 
(1) The Use of Proper Boots.—The preliminary to any and all 
treatment must be the selection of a suitable boot. The mechanical 
conditions which the foot is meant to fulfil should be studied in order 
that the foot may be put in the most favorable possible condition for 
Fig. 311. 
Boot of improved pattern (the inner edge is not quite so straight as it should be theoretically). 
restoration to its normal relation to the leg. Hampering and disabling 
footwear must be discarded. In many cases this measure alone is 
enough to secure correction of the pronation. The essentials of a good 
boot are as follows (Fig. 311): 
The inside line should be straight or nearly straight. 
The boot should be built to hold the foot in an adducted position; 
that it is to say, the forward part should be at an angle to the hind part 
if their axes are shown by lines drawn in the middle of the sole and the 
middle of the heel. This adducted position of the foot is the position 
of strength and the one which tends to combat the weakness represented 
in pronation. 
There should he plenty of width across the metatarso-phalangeal joint in order 
that the weight may be properly borne upon the ends of the metatarsals, and the 
sole of the boot should be as wide as the sole of the foot. 
The shank should be broad, not cut away at its inner aspect; it should be fairly 
stiff. 
This, in general terms, is the accepted form of boot by most writers who have 
studied the subject,1 although all sorts of modifications exist. In America, how- 
ever, it has been almost impossible to buy or have made a boot of this description, 
and the various “hygienic” and “reform” boots have, as a rule, in no way con- 
formed to these requirements. The shoe worn by children, which is symmetrical 
on both sides, tends to push the great toe out of the straight line, to hamper the 
muscles, and to favor pronation. The shoes worn by older children, known as 
misses’ sizes, are as bad, if not worse. Women’s boots in general, with the median 
pointed toe and the cutting away of the inside of the shank, favor the deformity. 
(2) By Raising the Inside of the Boots.—If pronation persists in spite 
of the application of a suitable boot, or if pronation is in the first place 
marked, the inner half of the sole and the inner half of the heel of the 
boot should be raised by having put on them a wedge-shaped piece of 
sole leather, which should be one-eighth or one-quarter of an inch in 
thickness at its base, the bottom of the wedge to correspond to the 
inner border of the sole and of the heel, and the apex of the wedge- 
shaped leather to the outer border of the sole. The patient should be 
cautioned against walking in the bare feet. Many cases of pronation 
1 Beely, Kirchoff der mensch. Fuss, Berlin. AFFECTIONS OF THE ARCH OF THE FOOT. 
663 
can be easily corrected at this stage by such a simple contrivance, which 
throws more weight on the outer border of the foot. 
(3) Muscular exercise should form a routine part of all treatment of 
pronated and flat-foot in the milder cases. The addition of massage 
makes it more efficient, and should form a part of the routine treatment 
in cases where it is obtainable. The cultivation of certain faulty 
muscles which should normally support the arch is, however, the essen- 
tial part of this aspect of the treatment. Among these exercises are 
forcible adduction of the foot against resistance, inversion of the sole 
and drawing up of the arch, walking on tip-toe, and rising on the toes. 
It is upon the education of the faulty muscles that the permanence of 
the cure must depend. Massage is of the greatest use in nearly all cases. 
(4) The Use of Pads, Plates, and Supporting Apparatus.—In cases 
where the arch has broken down the application of some supporting 
appliance to the arch is in most cases necessary. As a rule, appliances 
which are incorporated in the boot are unsatisfactory and clumsy. 
Fig. 312. 
Supporting plates for the flat and pronated foot 
Such shoes are made here and abroad, but they are exceedingly heavy 
and stiff. It is much better to have the supporting appliance inde- 
pendent of the shoe. The problem is to place the arch in a normal 
position which will rest the tired muscles, give the lengthened liga- 
ments a chance to contract, and place the foot under the most favorable 
conditions for improvement. Plates and springs of all sizes and shapes 
have been devised, and it matters little which one uses. 
A pad made of boiler felt may be cut of three or four layers, the bottom lay- 
ers overlying the top ones, thickest at the outside, which shall be applied to the 
arch of the foot in such a way as to afford a properly shaped support. The felt 
packs down, and, although it generally gives comfort at first, is not a permanent 
relief. In such cases similar plates may be made of leather and worn in the boots. 
Apparatus of this kind is likely to break down the shank of the shoe in severe 
cases. Of all forms of plates, the writer finds the most useful a rigid plate made 
of silicon bronze, which is a trade name for a composition metal (Fig. 312). This 664 
ORTHOPJEDIC SURGERY. 
plate follows the outside line of the sole of the foot, coming across to the inner 
opposite the great toe joint. At the inside it comes to the scaphoid bone and fits 
the outline of the heel. The essential of any plate is that it should fit comfortably 
and accurately. Without this the best results cannot be obtained. This may be 
done by having the plate shaped to a cast taken of the foot in a fairly correct 
position, or, what in the writer’s opinion is better, by having it shaped to the foot 
by the workman. Sensitive spots may be present which are not represented in 
the plaster cast, and if the plate presses upon these sensitive spots discomfort is 
caused. If the plate is tried on while being forged, these spots may be avoided, 
and in the writer’s mind much greater efficiency be obtained. 
The plates are not applied, in most cases, to cases of flat-foot as a 
permanent support, but in the hope that in connection with the use of 
muscular exercises a cure will be brought about and the plate may be 
dispensed with. It is a common experience for the arch to grow higher 
under this treatment, and at the end of three or four wreeks for the plate 
to fail to afford proper support. Pain begins again, which is relieved 
by raising the arch of the plate. In many cases of flat-foot the plate 
may be permanently discarded after a period of six months to several 
years. It may be repeated that absolute com- 
fort, due to accuracy of fit and the pursuance 
of special muscular exercises, is necessary to 
obtain this result. 
Fig. 313. 
In the severest cases of flat-foot the plate alone is 
not sufficient to keep the foot in place, and an outside 
upright running to the top of the calf should be added. 
This should terminate below in a horizontal piece of 
steel running along the outside of the foot. This piece 
and the plate should be included in a leather lacing 
which surrounds the foot and ankle as a loose boot 
might, but serves to pull the internal malleolus toward 
the outside upright. In other words, it is a plate with 
an outside upright which tends to invert the foot (Fig. 
313). 
If, however, the foot is stiff in the deformed 
position, no plate or appliance can be used until 
the foot has been rectified under ether and the 
arch restored to at least some extent. This is 
done by the exercise of manual force, and reten- 
tion for two or three weeks in the correct posi- 
tion is required. This is accomplished by the use of plaster-of-Paris 
bandages. 
Operative measures are rarely if ever required in eases of flat-foot. 
Sufficient force under ether is nearly always enough to rectify the 
deformity, as many changes which seem to be due to bony deformity 
are found under ether to be only contractions of the soft parts. 
Tenotomy of the peronei and other muscles, and even of the tendo 
Achillis, may be necessary. 
Stretching of the gastrocnemius muscle manually or by Shaffer’s 
shoe, or tenotomy of the tendo Achillis muscle, is of use in connection 
with flat-foot where dorsal flexion of the foot is limited to a right 
angle. This should be in connection with muscular exercise and 
massage. 
Hot and cold douches are of use in restoring the circulation where 
it is sluggish. 
Flat-foot plate with ankle 
support. TALIPES EQUINUS, CALCANEUS, VARUS, ETC. 
665 
Bony operations are rarely if ever advisable. They are described as 
follows : Ogston’s operation is a wedge-shaped osteotomy removing the 
astragalo-scaphoid joint. The scaphoid has been removed (Davy and 
Golding Bird). Gleich cuts through the os calcis transversely, and 
slips the posterior part downward to form a bony heel. There are 
various other mutilating operations which cannot be here described. 
Contracted foot is the name applied to the condition originally 
described by Dr. N. M. Shatter as “ non-deforming club-foot.” It is 
characterized by an increase in the height of the arch of the foot, so that 
the imprint is changed and only the front and back part of the foot touch 
the ground, leaving a clear space where the foot does not touch. This 
condition of contracted foot may be accompanied by pronation of the 
foot, and in many cases is associated with a limitation of dorsal flexion 
of the foot. 
It is diagnosticated by the tracing or by the fact that when the knee 
is extended the foot cannot be flexed beyond a right angle. This con- 
dition exists more often than one would suppose. In a recent series of 
tracings of healthy young women at least one case in ten showed what 
is known as a contracted foot. In the majority of instances it gives rise 
to no discomfort and the person is not aware of its existence. 
Contracted foot, however, is often the source of discomfort, and walking may 
be painful in a person whose arch is apparently normal. Where it is of long stand- 
ing a tight band can be felt in the plantar fascia when the foot is flexed dorsally, 
and pressure on this band is generally painful. At times a “ clawed ” condition of 
the toes is present in cases of long standing. Children with contracted foot fall 
easily and are clumsy. 
Very little is known of this condition as to its etiology or symp- 
toms. It has been for the most part overlooked, and is likely in the 
future to assume more importance in orthopaedic surgery. It is not 
unlikely that many cases of breaking down of the arch of the foot after 
fracture are due to the fact that flexion of the foot is limited dorsally on 
account of stiffness of the ankle. This condition is sometimes associated 
with metatarsalgia. 
An acute form of contracted foot has been observed by the writer which has 
been relieved by the support of the arch of the foot by a felt pad. 
The treatment most satisfactory in chronic cases is stretching of the plantar 
fascia and tendo Achillis by Shaffer’s shoe. Relief of the symptoms is generally 
immediate, and, although at first only lasting a few hours, at subsequent treatments 
it lasts a longer time, until after a few treatments weekly stretchings are all that 
are necessary. As a rule, they may be finally discontinued without relapses. 
Tenotomy of the tendo Achillis may be required in the severest cases. 
Talipes Equinus, Calcaneus, Varus, and Congenital Valgus. 
Talipes equinus is a condition in which the foot is plantar flexed, 
the metatarsus being pointed downward and the heel elevated. In a 
case of medium severity the patient walks upon the balls of the toes and 
is unable to touch the heel to the ground. There may rarely be such 
severe cases that the foot is completely turned over and the patient 
walks on the dorsal surface of the metatarsus. 
In connection with talipes equinus a condition is often noticed which 
has largely escaped attention. The phalanges are often in a “ clawed ’’ 
position. 666 
ORTHOPJEDIC SURGER Y. 
Pure talipes equinus as a congenital affection is rare. In the acquired 
form it results from infantile paralysis affecting the anterior muscles of 
the foot. It occurs as a post-hemiplegic 
contraction and in connection with 
spastic paraplegia, and sometimes with 
pseudo-hypertrophic paralysis. 
Fig. 314. 
It may be the result of traumatism from 
a posterior scar or it may be the outcome of 
a cellulitis in the muscles of the leg; it may 
be the symptom of muscular irritation in 
tubercular disease of the ankle; it may, like 
almost all deformities of the foot, occur as a 
symptom of hysteria. Patients who have 
been confined to bed for a long time with 
the weight of the bed-clothing resting upon 
their toes, upon their recovery may show 
signs of talipes equinus. The same is true of 
patients who, after fracture of the leg, for 
example, have worn for a long time a plaster- 
of-Paris bandage over the ankle, where care 
has not been taken to prevent the toes from 
pointing. Such patients show a temporary 
talipes equinus. 
There is a compensatory form of talipes 
equinus where shortening has persisted after 
hip disease or some similar affection, and the 
foot of the shortened side, from reaching 
down at each step, becomes plantar-flexed. 
Pathology. — The pathological 
changes are merely those which occur 
naturally from the long maintenance of an abnormal position. 
The diagnosis can be made by the simplest examination, provided 
the knee is kept completely extended while the limitation of motion is 
being determined. 
The slighter degrees of the deformity have been already considered 
under the heading of Contracted Foot. 
The prognosis is good in all cases, provided efficient treatment can 
be obtained. 
The treatment of the milder cases has already been discussed in 
speaking of contracted foot. It is doubted if the Shaffer shoe accom- 
plishes much in the severer cases. The limitation of mechanical treat- 
ment in talipes equinus is very marked. A satisfactory measure in 
nearly all cases is division of the tendo Achillis, and non-union is prac- 
tically never to be feared. Division of the plantar fascia subcutaneously 
is often necessary in the severer cases. Where both the plantar fascia 
and tendo Achillis must be divided, the former should be cut first in 
order to be able to stretch it after cutting, without at the same time 
stretching the divided tendon. The tendo Achillis may be lengthened 
to a definite extent by splitting it longitudinally and making the trans- 
verse cuts at different levels. In this way the two halves may be slid 
past each other and sutured at any definite point. 
Spastic Paralysis.—The question of the advisability of dividing the 
tendo Achillis and other contracted tendons in talipes equinus occurring 
in spastic paralysis has been left to the last. 
Talipes equinus. TALIPES EQUINUS, CALCANEUS, VARUS, ETC. 
667 
In cases where the intelligence is comparatively good, and where ataxia is not 
a disabling factor and exists only in a mild degree, much benefit may often be 
derived from cutting the tendons. This not only enables the child to use its legs 
more normally, but seems in some cases to result in improvement of the mental 
condition. It does not restore any power to the legs, but simply enables the mus- 
cles to be used to better advantage. In no case within the writer’s knowledge has 
harm resulted, and much benefit has often been observed. 
After division of the tendon for a deformity resulting from infantile paralysis 
or spastic paralysis the foot need not be over-corrected, as in the case of congenital 
talipes equino-varus. 
Osteotomy.—The removal of a wedge-shaped piece of the tarsus may 
be necessary in the severer cases of talipes equinus, but such cases are 
necessarily very rare. 
Arthrodesis, or the production of ankylosis at the ankle-joint, may 
be desirable in some of the severer cases of infantile paralysis where the 
muscles of the leg in general are severely involved. 
Talipes Varus.—Talipes varus is the name applied to a condition 
characterized by a turning inward of the sole, the foot being adducted 
and rotated inward at the medio-tarsal joint. Pure talipes varus, with- 
out an element of equinus, is a rare deformity either in the congenital 
or acquired form. The condition described in this article as congenital 
talipes equino-varus is, however, spoken of as talipes varus by such 
writers as Walsham and Adams. When talipes varus occurs, it results 
most often from infantile paralysis. 
The treatment of the deformity differs in no way from that of 
talipes equino-varus, the common form of which it resembles very 
closely. 
Talipes calcaneus is the name applied to a condition characterized 
by dorsal flexion of the foot, the heel being depressed and the metatarsus 
elevated. There is a condition known as pes cavus, which is character- 
ized by an arching of the sole of the foot. When severe, this is in most 
Fig. 315. 
Extreme degree of talipes calcaneus. 
cases connected with talipes calcaneus, and will be considered with it. 
Talipes calcaneus, however, may exist without any marked concavity 
of the sole of the foot, and pes cavus may exist without calcaneus and 
even with equinus. 
The deformity in talipes calcaneus may vary from a slight degree of 668 
OR TIIOPJEDIC S URGER Y. 
dorsal flexion to a degree where the dorsum of the foot can be flexed to 
touch the anterior surface of the leg. In cases of medium severity the 
patient walks upon the heel with the toes elevated, and when the affected 
leg is placed upon the ground it is necessarily unsteady and uncertain. 
The congenital variety of talipes calcaneus is comparatively rare. The deform- 
ity exists most frequently in the condition of talipes calcaneo-valgus. Acquired 
pure talipes calcaneus results most often from infantile paralysis of the posterior 
calf-muscles. It may occur also as a symptom of muscular irritation in tubercular 
disease of the ankle and from rupture of the posterior calf-muscles. It may also 
be the result of traumatic injuries and cicatrices1 involving the anterior muscles 
of the leg. The bony changes, which are of course the reverse of those resulting 
from talipes equino-varus, are merely the result of the maintenance of the foot in a 
vicious position, and they present nothing of importance. 
The diagnosis of talipes calcaneus is evident from inspection and 
manipulation. 
In pes cavus the anterior part of the foot is drawn backward and the 
arch is increased. It may occur alone as a congenital deformity, and 
in the acquired form it is most often of paralytic origin. It may be 
associated with the “ clawed ” toes already spoken of, but it occurs most 
frequently as the result of infantile paralysis in connection with talipes 
calcaneus. 
Treatment.—In the congenital cases of talipes calcaneus massage 
and manipulation are generally sufficient to overcome the dorsal flexion, 
possibly in connection with retention by plaster-of-Paris bandages. The 
same treatment may be useful in milder paralytic cases. In the latter 
cases a Taylor club-foot shoe, or some similar appliance which does not 
allow dorsal flexion of the foot beyond a right angle, is of use. Such 
a shoe prevents the foot from being rolled in or out and limits the 
vicious tendency. Tenotomy of the anterior tendons may possibly be 
required. 
Various operations have been proposed for the relief of talipes cal- 
caneus : 
(1) The tendoAchillis may be shortened. (Vide Vol. I. p. 515.) A 
piece of the tendo Achillis may be removed by Willett’s operation, or 
the tendon may be obliquely cut through, as advocated by Gibney, and 
the upper segment slid downward upon the lower, and the two portions 
sutured together by catgut while the foot is in a position of plantar 
flexion. Promising as these operations appear to be at first, the tendons 
are very apt to become elongated later where paralysis of the posterior 
muscles is complete. 
In cases where some muscular movement is left the operation is more promis- 
ing. Mr. Walsham transplants the tubercle of the os calcis to a lower position on 
the posterior surface of the bone, where it is fixed by an ivory peg while the foot 
is held in a position of extreme plantar flexion. This operation is also open to 
the same objection as the previous one. 
(2) A healthy muscle may be attached to the tendo Achillis by grafting; 
it to the side to supplement the action of the paralyzed gastrocnemius 
and solens. A portion of the outer margin of the tendo Achillis is 
removed, and to this freshened surface the ends of the divided peroneal 
tendons are sutured by fine silk. Probably other muscles could be sub- 
stituted for the peroneal tendons, provided that healthy muscle could 
1 Bayer, Prag. med. Woch., 1873, 16. PARALYTIC DEFORMITIES OF THE FEET AND LEGS. 
669 
be chosen which in their contraction should pull upward on the tendo 
Achillis. The grafting of a healthy muscle gives far more satisfactory 
results than simply shortening the tendon. 
(3) Arthrodesis of the ankle-joint is a useful measure in cases of 
complete paralysis of the leg the result of infantile paralysis. This 
operation consists merely in an incision as if for resection of the ankle- 
joint. The cartilages of the joint are removed by a curette or gouge, 
by which mobility is destroyed and the foot is held flexed at a right 
angle until union occurs. When the ankle-joint is obliterated it is often 
desirable to do away with the mobility of the medio-tarsal or metatarso- 
phalangeal joints, which is likely to become a troublesome factor. This 
is done by destroying the synovial membrane between the bones. 
Bony operations are very rarely necessary for talipes calcaneus, 
although in one case the scaphoid and part of the adjacent bones were 
removed. 
Pes cavus may require for its relief the division of the plantar 
fascia and possibly some of the tendons. 
The mixed forms of deformity of the foot described under the com- 
pound names of calcaneo-valgus, etc. have no special features of surgical 
interest, and have been sufficiently well covered by the description of 
the simpler forms. 
The terms dorsal flexion and plantar flexion, wherever they appear in this article, 
have been used for purposes of clearness. 
It is probable that the development of tendon-grafting—that is, grafting the 
proximal end of the tendon of a healthy muscle upon the distal end of the tendon 
of a paralyzed muscle—will have an important place in the surgery of the future. 
Talipes Valgus.—Acquired talipes valgus has been spoken of already 
under the section relating to flat-foot. 
Congenital talipes valgus, occurring without an element of calcaneus, 
is so rare that its existence has been denied by some writers. It un- 
doubtedly exists, and is sometimes associated with absence of the fibula 
or some similar malformation. 
Its treatment differs in no way from that of the acquired variety. 
Paralytic Deformities of the Feet and Legs. 
The deformities of the feet which result from infantile paralysis 
have been for the most part considered in the previous section under 
the headings of Talipes Equinus, Calcaneus, etc. Infantile paralysis, 
in general the most frequent cause of these acquired deformities of the 
feet, causes disability in two ways : (a) by leading to contractions of the 
legs and feet in deformed positions, like talipes equinus, flexed knee, 
and the like; (6) by rendering the limbs flaccid and unable to bear 
weight. The extent and distribution of the paralysis determine this 
disability. 
The diagnosis is made partly from the history. In infantile paral- 
ysis a child in its first dentition is suddenly attacked, most often in the 
night, by a feverish spell, which is followed by loss of power, perhaps 
in one of the legs. The tendon reflexes in the knee of the affected side 
are lost or diminished, and the paralyzed muscles show the reaction of 
degeneration. 670 
ORTHOPEDIC SURGERY. 
With regard to the prognosis, it may be said that no case of infan- 
tile paralysis, however severe, is beyond the possibility of improvement 
by mechanical or operative means. 
In early cases of infantile paralysis, and in cases characterized by 
tlaccidity rather than by contractions of the muscles, the requirement is 
for apparatus which shall give support to the leg, so that it may be 
used and held in a comparatively normal way. Tlius the stretching of 
paralyzed muscles may be avoided, and contractions of the joints in 
deformed positions are rendered less likely. 
The chief requirement in apparatus for 
paralysis of the leg is that it shall hold the* 
knee extended and control the ankle, so 
that it shall not turn to one side or the other. 
This renders the leg able to bear the body- 
weight. The control of the ankle is best 
obtained by the use of the Taylor club-foot 
shoe, used either at the inside of the foot or 
outside with an outside upright. To this 
shoe is attached whatever appliance may be 
necessary to hold the leg straight. The 
general principle is shown in Figs. 316 and 
Fig. 318. 
Fig. 316. 
Fig. 317. 
Supporting appliance in paralysis of the anterior thigh- 
muscles (Bradford and Lovett). 
Supporting appliance for paralysis 
of the right leg. 
-H (. As a supporting apparatus it is equivalent to a skeleton plaster-of- 
Paris bandage supporting the entire leg and ankle. Accurate fitting is 
essential, and leather lacings give a better distributed support than do 
bands and straps (Fig. 318). 
Where the hip-muscles, and especially the adductors of the thigh, 
are paralyzed, the leg uprights should be joined to a leather jacket or a 
leather band embracing the pelvis. HALLUX VALGUS. 
671 
Where contraction in a deformed position exists at any joint, it must be over- 
come before the legs can be properly used or fitted with apparatus. At the hip the 
deformity is generally flexion, and the resistant structures below the anterior supe- 
rior spine of the ileum and on the outside must be cut subcutaneously or by open 
excision. As the operation must sometimes go as deep as the psoas tendon, the 
open incision is the better operation. After operation a weight-and-pulley trac- 
tion should be applied. 
Flexion deformity at the knee may be accompanied by subluxation of 
the tibia and by a marked degree of knock-knee, which may not be 
noticed until the flexion has been overcome, when it is very evident. 
Mild cases of flexion at the knee are best treated by a subcutaneous, or 
preferably an open, incision of the hamstring tendons, and, if necessary, 
of the resistant structures at the back of the joint. In the worst cases 
this fails to bring the subluxated tibia forward, and one has to resort to 
the use of extreme force or to some cutting operation. This latter is 
decidedly preferable, and the excision of a wedge-shaped piece of bone 
yields by all odds the best results. This does away with flexion deformity 
and knock-knee at the same time, and obliterates the motion of the joint. 
At the ankle the operation has been already described as arthrodesis 
in the previous section. 
Tenotomy as applied to the relief of spastic paralysis has been already 
considered in a previous section. 
Hallux Valgus 
This is the name applied to an outward deviation of the great toe at 
the metatarso-phalangeal joint. The deviation to some extent is present 
in practically all adult feet at the present day, and it is only when the 
throwing outward of the great toe becomes extreme that it is commonly 
spoken of as a deformity. In the normal foot it was pointed out by 
Meyer that a straight line drawn backward, prolonging the middle line 
of the great toe, should pass through the middle point of the heel. 
Although this may be the case in young children, it is almost impossible 
to find a foot of this description in an adult, at least in the large cities. 
So long as children are compelled to wear shoes of the present shape 
hallux valgus will be commonly found. It is hard to say where the 
condition recognized as normal ends and where the condition to be de- 
scribed as hallux valgus begins. In the etiology of the affection no fur- 
ther cause is needed than what has already been named. The deformity 
is associated with osteo-arthritis in some cases, but probably does not 
stand in a causal relation to the condition. 
Pathology.—One finds that the first phalanx is displaced more or 
less according to the severity of the deformity on to the outer side of 
the head of the first metatarsal. The internal ligaments and muscles 
are stretched and the external ligaments and muscles shortened and con- 
tracted. The tendons of the sesamoid bones are displaced over the 
inner aspect of the head of the metatarsal bone, and a bursa may de- 
velop which is apt to become inflamed on pressure and is known as 
bunion.1 
The chief symptoms of the deformity result from pressure over the inner 
aspect of the deformed joint. The bursa often becomes inflamed and suppurates, 
1 Revue d’ Orthopedic, September, 1892. 672 
ORTHOPEDIC SURGERY. 
discharging from a small opening in the centre. This condition is likely to con- 
tinue permanently. Inflammation of the distorted joint often occurs, which may 
result in the deposit of osteophytes and in bony grating. The bursa often com- 
municates with the joint and suppuration may result. When the deformity is 
severe, it is useless to try to remedy it by making the patient wear a boot with a 
straight inside edge. Rather a large piece of leather should be nailed to the last 
on which the boot is made, which pad should come over the situation of the affected 
joint, allowing sufficient room to prevent pressure. Under these conditions uncom- 
fortable symptoms are often avoided. Splints for the relief of milder forms have 
been devised which press the toe in by using the foot as a point from which to 
pull. Sayre uses a buckskin cot which connects with elastic webbing running 
along inside of the foot and attached to a piece of adhesive plaster on the heel. 
For severe cases, where the bursa is inflamed and the joint involved, it is much 
simpler to excise a wedge-shaped piece from the metatarsal and the plialanx, in- 
cluding and obliterating the joint. Excision of the head of the metatarsal bone 
may be done, which may leave the patient with a fairly movable joint, but excision 
of the joint, as a rule, gives the best results and affords an opportunity for the re- 
moval of the bursa at the same time. 
Hallux varus is a condition in which the great toe deviates inward 
to an abnormal extent. It occurs very rarely as a congenital affection. 
It rarely requires severe treatment. Manipulation and retention with 
a splint are generally sufficient. If need be, the internal lateral liga- 
ment of the foot may be divided and the toes replaced in a correct 
position. 
Metatarsalgia. 
Metatarsalgia, or Morton’s painful affection of the foot, as it is 
often called from Dr. Thomas G. Morton, who first described it in 1876, 
is a condition characterized by acute pain located between the distal 
ends of the outer metatarsal bones. The affection seems to be due to 
a neuralgia of the plantar digital nerves, and especially the branches in 
the neighborhood of the fourth metatarsal, where they seem particularly 
liable to injury. The affection attacks most often young adults, and is 
more common in women than in men. It seems to have its origin in a 
certain number of cases in the persistent use of ill-fitting shoes ; it arises 
also from slight sprains and wrenches of the foot. It may, however, 
occur apparently spontaneously. It may be acute and quickly subside, 
or it may become chronic. Local tenderness is generally present, but 
no swelling. The most characteristic symptom is a “cramp” in the 
foot, which may make it imperatively necessary to remove the boot at 
once wherever the patient may be. 
The affection is probably in most cases associated with some abnormality in 
the arch of the foot, such as contracted foot, pronated foot, or flat-foot. In some 
instances it is associated with obliteration of the transverse arch of the foot, as 
pointed out by Goldthwait. It seems probable that with the more careful study 
of the arch of the foot some abnormality will be found to explain all cases. 
Iii the treatment the first aim should be to seek fora cause for the 
affection in some abnormality of the arch, and not only should this be 
corrected, but the use of proper boots should be insisted upon. If no 
cause can be found, acute cases are best treated by bandaging and sooth- 
ing applications. Very severe cases may require excision of the head 
of the fourth metatarsal hone. Most cases, however, in practice can be 
relieved by the detection and treatment of the condition of which the 
pain is a symptom. ANKYLOSIS. 
673 
Ankylosis. 
Ankylosis is the term used to designate loss of mobility in a joint. 
When this loss of motion is not complete, but where motion is limited 
by structural changes, the condition should be spoken of as partial 
ankylosis. The term true ankylosis should be used wherever firm union 
exists between the ends of the bones, whether it is bony or fibrous 
(Warren). Ankylosis often occurs— 
(1) As a result of tuberculous bone disease where the cartilaginous 
and synovial surfaces of a joint have been destroyed by granulation- 
tissue, and a transformation of this into connective tissue and bone has 
taken place. It also occurs under these conditions as the result of cica- 
tricial contractions in the capsule of the joint and periarticular struc- 
tures. Pathological luxations may also occur which impair motion. 
(2) As a result of suppurative and septic synovitis, non-tubercular, 
where a similar process to that described above occurs. 
(3) As the result of rheumatoid arthritis, where it is due to the wear- 
ing away of the cartilage and to the formation of osteophytes around 
the sides of the bones. 
(4) After fractures into and near the joints, the result of synovial 
inflammation, of displacement of the bones of the articulation, and of 
cicatricial contraction in the muscles and periarticular structures. 
As a rule, bony ankylosis is not present until a year or two after the 
acute process. Marsh, however, reported a case where bony ankylosis 
of the ankle-joint was present one month after suppuration began. 
The most important question in connection with ankylosis is whether or not 
it is likely to occur as the result of prolonged fixation of a joint. The statement 
has been so often made that such is the case that a state of mind described as 
“ ankylopliobia ” has arisen in the mind of many surgeons which leads to the pre- 
mature removal of splints in fractures and in diseases of the joints. Phelps showed 
in some experiments on dogs that fixation of the healthy joint did not produce 
ankylosis. The joints were immobilized and the dogs were killed at the ends of 
six months, three months and a half, and two at five months, and in all cases the 
joints were normal and a section of the bone showed no abnormality. The con- 
clusions which Phelps drew were that a normal joint would not become ankylosed 
by simply immobilizing it for five months; that movement is not necessary to pre- 
serve the normal histological character of a joint; and that where ankylosis occurs 
in the hip-joint it is not due to prolonged rest. Reyher found that in dogs after 
fixation for sixty-two days or more, although the synovial membrane remained 
normal, the capsule began to thicken, and that the cartilaginous surfaces where not 
in contact began to degenerate, but in the cases of longest duration (about one 
year) inflammation did not occur. 
From what has been said, and from any study of the pathology, it 
must be plain that ankylosis is the result of inflammation, especially of 
prolonged type. Whatever favors or increases this inflammation pre- 
disposes to ankylosis, and any measure which tends to quiet inflamma- 
tion tends to arrest ankylosis. Consequently, whatever treatment is 
necessary to subdue inflammation in the joint should be pursued, regard- 
less of any preconceived notion that fixation will produce ankylosis, 
on the ground that it is the inflammation which is the harmful factor, 
rather than any amount of fixation. This applies particularly to the 
early removal of splints in fractures, such as those of the elbow-joint, 
and in the case of brisement force as a measure in the treatment of stiff 
joints. 674 
ORTHOPEDIC SURGERY. 
Brisement forc6 is so often followed by equal if not greater stiffness 
than before operation that one seeks a physiological cause. 
In the dogs experimented on by Reyher the joints were moved after prolonged 
fixation, and the dogs were then immediately killed, that the joints might be 
examined. It was found that when the fixation had lasted over a month there 
was infiltration of the periarticular structures and discoloration of the synovial 
fluid, while if the fixation had been longer, as for some months, bloody effusion 
took place. In general, brisement force is likely to cause exudation, and in that 
way to limit the amount of motion. If it be desired merely to correct the position 
of an ankylosed joint, the process is very serviceable, but in bony ankylosis it is 
useless and may lead to fracture. Force, gently and judiciously used as passive 
motion in the later stages of fracture, is a measure of the greatest value, but if 
ankylosis is feared, massage is gentler and safer. Where ankylosis has occurred, 
some accurate cutting operation is often to be preferred to brisement force, which 
may do an unexpected amount of harm. In short, the causes of ankylosis are 
such that the condition is not likely to be relieved by one rough manipulation, 
which is almost sure to start up still further inflammation. 
The Mechanical Treatment of Joint Disease. 
The mechanical treatment of joint disease depends for its efficiency 
upon three things which it tries to accomplish. In this it follows 
Nature’s lead, aiming to do artificially what she indicates in symptoms 
and pathological processes. These three aims are—(1) fixation of the 
affected joint, (2) protection from weight-bearing, and (3) distraction of the 
joint surfaces where possible. 
Mechanical Treatment of Hip Disease.—The term “ hip disease ” 
will be used here as synonymous with tuberculous inflammation of the 
hip-joint. The mechanical treatment of hip disease may be conducted 
either during recumbency in bed or by ambulatory apparatus. In gen- 
eral, modern opinion leans toward the latter method. 
Treatment by recumbency is to be adopted when the joint is sen- 
sitive to manipulation and when attempts at going about with suitable 
apparatus cause pain and irritation. It is to be adopted when deformity 
of the leg in an adducted, abducted, or flexed position is present; also 
when it is desired to avert the formation of a threatened abscess. 
During treatment in bed the patient should be secured flat on his back by 
means of the rectangular gas-pipe frame invented by Dr. Bradford (Fig. 319). 
Fig. 319. 
Bradford’s bed-frame. 
The frame is covered with stout cotton cloth, leaving a space under the pelvis, so 
that the child may be placed on a bed-pan without being removed from the frame. 
The frame should be a little longer and a little wider than the child, and straps should THE MECHANICAL TREATMENT OF JOINT I)[SEASE. 
675 
go across the chest to secure it to the frame. The use of this frame to secure fix- 
ation for the body of the child and a definite basis from which to exert traction is 
an essential in the scientific routine treatment of hip disease (Fig. 320). Exten- 
sion is then made in the usual way by a weight and pulley from the foot of the bed. 
Fig. 320. 
Author’s weight-and-pulley apparatus for bed-traction in hip-joint disease. 
Traction should always be made in the line of deformity; that is, the child’s pelvis 
is placed squarely, and traction should be made upon the leg in the line in which 
it points (Fig. 321). As the leg improves, it may be lowered more nearly to the 
normal position each day. The child should be secured to the bed-frame by means 
Fig. 321. 
Bed-traction in a case of flexion and abduction (Lovett; by permission of the Trustees of the 
Fiske Prize Fund). 
of perineal bands. Under the circumstances mentioned traction of from ten to 
fifteen pounds should be borne if possible. The traction is made by the ordinary 
sticking-plaster extension, as applied in Buck’s method for fracture of the thigh. 
Traction during recumbency may be made by the long Taylor splint about to 
be described under ambulatory treatment, but it is generally less comfortable than 676 
ORTHOPAEDIC SURGERY. 
the method just mentioned. Treatment by recumbency is not to be advocated as 
a routine measure, but simply under the conditions noted. It is to be discontinued 
as soon as the deformity has disappeared or as soon as the child can go about with- 
out pain. It is desirable, however, that children should sleep strapped to the frame 
at night during the acute stage of hip disease. 
The ambulatory treatment of hip disease may be considered 
under three headings: (1) treatment by protection; (2) by fixation; 
and (3) by traction. 
(1) Treatment by protection alone has been used under the name of 
the physiological method of Hutchison, where the child was allowed 
to go about using a crutch with a high sole on the well 
foot, and allowing the diseased leg to swing. The method 
is very slightly better than no treatment at all, and has 
been practically abandoned. 
Certain methods described under the name of “ traction 
methods” are probably nothing but methods of treatment by pro- 
tection. Such, for example, is the treatment by the so-called 
ischiatic crutch (Fig. 322). in which scarcely perceptible traction 
is made by means of leather straps attached to the bottom of the 
splint. The traction in this case does little more than steady the 
leg, and it cannot be supposed to have any effect upon the joint. 
In this case the splint serves to transfer the weight from the hip- 
joint to the perineal band of the crutch, which bears upon the 
tuberosity of the ischium. Useful as this method is during con- 
valescence, it is not by most surgeons considered satisfactory 
during the acute stage. 
Treatment by Fixation.—Nature furnishes the indication 
that the joint should not be moved during hip disease, by 
holding the hip firmly by tonic spasm of the muscles con- 
trolling the joint. In general relief is experienced by 
fixation. 
The most efficient method of treating hip disease by 
fixation is that of H. O. Thomas of Liverpool (Fig. 323). 
The Thomas splint consists of a bar of soft iron reaching 
posteriorly in the middle line of the leg from the angle of 
the scapula to the lower third of the leg. It is shaped to 
fit the curve of the buttock, Above, it terminates in a 
chest-band which should encircle three-fourths of the chest. There is 
also a semicircular thigh-band which should be placed an inch or two 
below the perineum, and a leg-band should terminate the splint at the 
bottom, which should encircle two-thirds of the calf. The splint is 
applied as shown in Fig. 324, secured to the body by means of a 
bandage connecting the ends of the chest-piece and running over the 
shoulders. The leg is secured to the splint by leather straps or by a 
common bandage, a high sole is put upon the well foot, and the patient 
is allowed to go about on crutches. The splint furnishes fairly good 
fixation; it is cheap and simple, and is in general use throughout Eng- 
land, where the results are satisfactory. In America this method of 
treatment is not regarded with favor, as a rule. It makes no traction 
and supplies necessarily imperfect fixation. Again, inasmuch as no 
traction is exerted to counteract muscular spasm, and thus to keep the 
head of the femur from being crowded into the acetabulum by muscular 
force, and thus wearing away the upper rim, there must result in severe 
Fig. 322 
Judson’s peri- 
neal crutch. THE MECHANICAL TREATMENT OF JOINT DISEASE. 
677 
cases subluxation, shortening, and elevation of the trochanter above 
Nelaton’s line. In general, the splint is hard to adjust, difficult to keep 
in place, and does not allay pain as traction does. 
Other methods of fixation which are advocated are a plaster-of-Paris spica 
bandage embracing the chest (Fig. 325) and diseased limb, a leather splint of 
about the same shape and accomplishing the same purpose, and various wire, 
iron, and leather splints aiming at the same purpose (Fig. 326). 
Treatment by Traction.—The use of traction in hip disease rests 
upon the theory that by efficiently applied traction the surfaces of the 
hip-joint can be separated from each other. In this way two surfaces 
of diseased and softened bone are kept from wearing upon each other. 
Pain is diminished, the pro- 
cess of healing is promoted, 
because the greatest amount 
of quiet in the joint is pro- 
duced by this method. 
Fig. 323. 
Fig. 324. 
Thomas splint applied with patten and crutches (Ridlon) 
The splint in its simplest form, not 
yet padded or covered (Ridlon). 
In connection with treatment by traction, protection should be 
obtained by the use of a high sole and crutches; fixation should be ob- 
tained by having a tightly-fitting pelvic band surrounding the pelvis; 
and the activity of the child should be limited by insisting upon some 
hours of recumbency during the day. The combination of the three 
methods of protection, fixation, and traction combined in the treatment 
to be described affords theoretically and practically the best chances of 
securing a good result in hip disease. It has been demonstrated1 that 
in the diseased hip-joints of children traction of ten to twenty pounds 
1 Bradford and Lovett, New York Med. Journ., Aug. 4, 1894. 678 
ORTIIOPJEDIC SURGERY. 
induces lengthening of the leg from one-eighth to one-halt inch. 
Eliminating sources of error, it becomes evident that this lengthening 
in the leg must be caused by a separation of the joint surfaces. Conse- 
quently, it may be assumed that traction applied in sufficient force 
serves to separate the head of the femur from the acetabulum, and 
traction to be of use must be applied in force sufficient to accomplish 
this. It is not likely that it is done by traction of less than ten pounds. 
The traction must therefore 
be used intelligently with 
this in view. 
Traction when the patient 
is going about can be most 
easily produced by the long 
traction splint know as the 
Davis, Sayre, or Taylor 
splint. The special form 
Fig. 325. 
Fig. 326. 
The plaster-of-Paris bandage (Lovett; by permission 
of the Trustees of the Fiske Prize Fund). 
Vance’s moulded leather splint. 
of this splint is a matter of very slight consequence, provided that its 
aim be kept in view. The object is to provide a rigid perineal band and 
an upright running the length of the leg. The perineal band is to fix 
the pelvis and to provide a basis for counter-extension when the leg is 
pulled down by the foot-piece at the bottom of the upright. 
To the leg is applied a sticking-plaster extension, such as is used in the bed- 
extension. This is fastened to a windlass on the foot-piece of the splint. Perineal 
bands pass from the front to the back of the rigid pelvic, back, and afford a basis for 
holding the pelvis when the leg is pulled downward. The splint is one which may 
he made by a blacksmith, yet it is capable of the greatest nicety of construction. 
The forms most commonly used are shown in the illustrations. The pelvic band 
should fit tightly to the pelvis, and the upright of the splint may be curved to con- 
form to the outline of the leg. The perineal bands should be made of webbing THE MECHANICAL TREATMENT OF JOINT DISEASE. 
679 
covered with canton flannel, and any apparatus which will pull the straps down- 
ward may be used for the windlass at the bottom of the splint. The writer has 
described a gas-pipe splint1 (Fig. 328), which can be made for a dollar or two, 
which serves fairly well, but from which traction is to be made by means of 
leather straps attached to the foot-piece and buckled into the sticking-plaster 
extension. 
Such, roughly, is the splint in general use in the hands of American 
orthopaedic surgeons. It does not 
furnish complete fixation to the pel- 
vis, but partial fixation. Under 
proper circumstances it probably 
does induce separation of the femur 
from the acetabulum. Where it is 
used pain should be allayed at 
once, and night-cries or irritability 
of the joint are a sign that matters 
are not going well, and that the 
Fig. 327. 
Fig. 328. 
patient is probably allowed too much activity or that the apparatus is 
not properly cared for. 
Splint for hip-joint disease. 
Diagram of cheap gas-pipe hip-splint, 
With this treatment motion should increase in the joint, elevation of the tro- 
chanter should not occur, abscess-formation should be uncommon, and the general 
condition of the child should improve. If the child is allowed to walk upon the 
bottom of the splint, the traction will inevitably become intermittent, because 
when the weight is borne upon the splint the traction straps are loosened and less 
pull is made upon the hip than when the weight is on the other ieg. Consequently, 
at one time the splint pulls harder than it does at others, and on theoretical 
1 Boston Med. and Surg. Journ., Mar. 12, 1891. 680 
ORTHOPAEDIC SURGER Y. 
grounds it is easy to see that this is not consistent with the best results. Crutches 
and a high sole upon the well foot should be used during the acute stage. It is an 
essential part of the treatment that the patient should during a part of the day be 
kept quiet in a recumbent position. The routine adopted by the writer is as fol- 
lows : The patients are not allowed to get up until ten o’clock. They are quiet 
one hour in the morning and two hours in the afternoon, going to bed at six or 
seven. In this way better results are obtained than under other conditions. 
The splint of I)r. Phelps is probably the most important modifica- 
tion of the long traction splint (Fig. 330). It aims at securing better 
fixation by an arm encircling the thorax in addition to the pelvic arm, 
and it theoretically provides lateral traction in addition to that in the 
Fig. 329. 
Fig. 330. 
Brace for hip-joint disease, with extension and 
counter-extension provided for. 
Phelp’s hip-joint brace. 
length of the leg. It is doubtful if the splint really exerts lateral 
traction; and, indeed, the question of the value of lateral traction is 
one which is still unsettled. There are other modifications of the long 
traction splint in use in Germany, but they contribute nothing essential 
to the traction treatment. 
Treatment by traction should be used until some months after mus- 
cular spasm has disappeared from the joint, for relapses are common, 
and if traction is discontinued too soon, rigidity returns and the disease 
again becomes active. When the acute stage is sufficiently quieted to 
allow the application of a convalescent splint, partial protection to the THE MECHANICAL THE A TMENT OF JOINT DISEASE. 
681 
joint will be all that is required. Consequently, if the traction splint 
is cut off and is made to fit into a slot fastened into the sole of the boot 
in such a way that the splint shall be longer than the leg and that the 
bottom of the foot shall not touch the bottom of the boot, sufficient pro- 
tection for practical purposes may be provided. In this way the patient 
in walking does not have the full impact of the step come upon the hip- 
joint, but takes it upon the perineal band of the splint. A splint of 
this sort should be worn two or three years after the active treatment 
has ceased, and should be discontinued gradually. 
Hip-abscess.—With regard to the occurrence of hip-abscess, it is 
probable that the careful carrying out of the traction method as 
described will in the majority of cases avert its occurrence. In a series 
of cases taken from the reports at the Children’s Hospital, in 574 cases 
under ambulatory treatment only 18.7 per cent, developed abscess.1 In 
Fig. 331. 
Ward-wagon (Children’s Hospital, Boston, Massachusetts). 
an earlier series of cases reported by Gibney and the London Clinical 
Society, 60 or 70 developed abscess. The reason for the small per- 
centages at the Children’s Hospital is probably the fact that cases under 
ambulatory treatment are at once admitted to the hospital wards when- 
ever sensitiveness or deformity of the joint occurs, and are treated by 
recumbency. 
Malum Coxse Senile.—The form of disease of the hip occurring 
in elderly persons in connection with chronic rheumatoid arthritis has 
generally been regarded as an intractable and hopeless affection. It has 
been pointed out by H. L. Taylor2 that rest and traction of the diseased 
hip, followed by protection by means of the splint described above, 
should be followed by much relief of the irritation, and in many cases 
by a permanent improvement of the diseased joint. 
Disease of the Knee-joint.—In tumor albus or chronic inflamma- 
tion of the knee-joint the indications are, as in hip disease, for protec- 
tion, fixation, and traction. 
Partial fixation can be obtained by means of the ham-splint or by 
1 Lovett, Diseases of the Hip, p. 117. 2 N. Y. Med. Journ., Dec. 15, 1888. 682 
ORTHOPEDIC SURGERY. 
the plaster-of-Paris or leather, silicate, or dextrin bandages applied to 
the leg. Plaster-of-Paris bandages as routine treatment for tumor albus 
are not suitable for continued use, as they loosen and become dirty, and 
afford less fixation that one would suppose on account of the elasticity 
of the muscles by which the femur is surrounded. To control the joint 
in a proper way the bandage should extend from the ankle to the groin, 
and should not stop at the middle of the thigh. It should be as tightly 
applied as is comfortable. This bandage, in connection with the use of 
a high sole on the well foot and crutches, furnishes protection and fixa- 
tion, and is a fairly efficient mode of treatment. It does not, however, 
Fig. 332. 
The Thomas knee-splint. 
provide for traction, which, although not as important as at the hip- 
joint, is of use in most cases. Unless the patient lias a high sole on the 
well foot and uses crutches the joint is not protected even if a plaster-of- 
Paris bandage is applied, and the case is not being properly treated if 
the ends of bones are allowed to jar together in the motion of walking. 
The Thomas knee-splint is the most satisfactory apparatus in general 
for the treatment. It consists of a ring of iron set at an angle of 45° 
to the inner one of two uprights which project below the foot. The 
ring of iron is padded and fits closely the upper part of the thigh, so 
that in walking the patient receives support from the perineum and 
bears no weight upon the knee. The ring is irregularly ovoid in shape, 
drawn out at the inner posterior angle. This splint is shaped to the THE MECHANICAL TREATMENT OF JOINT DISEASE 
683 
leg and fitted with leather lacings to the thigh and the calf, which fur- 
nish excellent fixation. The splint projects below the bottom of the 
foot, and the transverse bar at the bottom may be used to make traction 
from the sticking-plaster extension, which is applied to the leg, reaching 
to the knee. A high shoe is placed upon the well foot, and the patient 
is allowed to go about either with or without the use of crutches. In 
cases where the muscular spasm is marked and the joint is irritable, and 
there is flexion, the Thomas splint is not so satisfactory as the more 
expensive splint shown in Fig. 333. This is practically a long traction 
splint, such as is used at the hip, but jointed at the knee, so that trac- 
tion can be made at any angle. It is pro- 
vided with buckles for pulling upward on 
the thigh as well as downward from the 
knee. The splint can make traction at 
any angle at which it is set, and it has the 
advantage of combining fixation, traction, 
and protection in the same apparatus 
(Fig. 332). A cheap splint has been 
Fig. 333. 
Fig. 334. 
Long, jointed traction-splint, 
The Taylor knee-splint. 
described by Taylor where buckles sewed to webbing are incorporated 
in a plaster bandage, and the ends of the traction straps turned over 
the ends of the bandage and buckled into them (Fig. 334). 
The chief difficulty in the treatment of tumor albus comes in the 
cases where permanent flexion of the knee occurs. Under these cir- 
cumstances the following course may be pursued : 684 
OR TilOPrEDIC S UR GER Y. 
(1) The knee may be straightened by force while the patient is under 
the influence of ether, and a plaster-of-Paris bandage applied. Gold- 
thwait’s genuclast enables one to exert great force gradually and with 
safety. The apparatus extends the knee and at the same time presses 
forward the head of the subluxated tibia. 
(2) By the application of a plaster bandage to the leg in the fixed 
position the muscular spasm is quieted and relaxed, so that after some 
days, when the bandage is removed, the knee can be placed in a 
straighter position. By a succession of plaster bandages the irritation 
is quieted, and at each application the knee may be straightened some- 
what. This method is to be used until the leg is straight. 
(3) An apparatus known as the Billroth splint is occasionally used. 
A plaster bandage is applied to the limb, and in this bandage are incorporated 
two hinges attached to broad curved iron plates. These hinges are placed over 
the lateral aspects of the joint, so as to allow antero-posterior motion when the 
bandage is cut at the knee. After the bandage has hardened a circular division 
of the plaster is made at the knee and the front of the bandage is cut away. Into 
the slot at the back of the knee are inserted wedges of increasing size until the 
limb is straight. The splint exercises considerable pressure and may cause 
sloughs. 
(4) Flexion may be corrected by traction made in the line of deform- 
ity, which quiets the irritability of the muscles and allows the limb to 
be gradually straightened. The way in which this traction is applied 
is by the traction splint above mentioned. 
When muscular spasm and joint irritability have been absent for some months, 
the ends of a Thomas splint may be cut and turned in to a slot in the sole of the 
boot, so that the patient walks just as with the protection splint described under 
Hip Disease, with the heel of the foot not touching the heel of the boot and sus- 
pended by the perineal ring. 
The treatment of ankylosis of the knee in a faulty position was discussed under 
the heading of Ankylosis. 
Chronic rheumatoid arthritis, where it is manifested in irritation of the knee- 
joint, may be treated by the same apparatus, providing fixation and traction—as 
are used in the tuberculous variety. 
Ankle-joint Disease.—Chronic tubercular disease of the ankle-joint 
and tarsus must be treated by fixation and protection. Traction is not 
applicable. 
Fixation may be furnished by a plaster-of-Paris bandage applied to the ankle 
and reaching to the upper part of the leg, or it may be furnished by a skeleton 
bandage made of steel, which consists of a metal sole-plate and two uprights run- 
ning to the top of the calf, where they terminate in a posterior curved band. A 
leather lacing holds the foot on to the foot-plate, and another lacing confines it to 
the calf and the uprights. This splint offers no special advantage over the plaster 
bandage, except that it is cooler and more comfortable. 
Protection to the diseased ankle-joint is most readily furnished by 
having the patient wear also a Thomas knee-splint, which comes below 
the foot and protects from weight-bearing: unless this is done it is 
impossible to keep the child from walking. 
AYhen deformity of the ankle-joint, either in the position of plantar 
or dorsal flexion, is present, it is a symptom of muscular irritability, 
and this muscular irritability is most easily allayed by a succession of 
plaster bandages, affording fixation and applied as described in knee- 
joint disease, in the hope of each time securing a better position. THE MECHANICAL TREATMENT OF JOINT DISEASE. 
685 
Disease of the metatarsus is to be treated in the same way as disease 
of the ankle-joint. 
Diseases of the Shoulder, Elbow, and Wrist.—In diseases of the 
upper extremities the question of protection from weight-bearing is not, 
of course, to be considered, and traction is not, as a rule, practical. 
Consequently, one is reduced merely to treatment by fixation in chronic 
tuberculous disease of the upper extremities. Fortunately, they are 
not very common and need no extended discussion. 
At the shoulder one ordinarily applies a plaster-of-Paris spica bandage, 
or holds the elbow at the side by restricting the use while the arm is 
confined in a sling. In certain cases where abduction of the arm is 
present, due to muscular spasm, it is an advantage to support the arm 
at a right angle to the body by means of a specially constructed wire 
splint, which, taking its basis from the chest, holds the arm in that 
position. 
Disease of the elboiv is treated by fixation, either by means of a 
plaster-of-Paris splint from the wrist to the shoulder, holding the elbow 
at a right angle, or by means of a tin internal angular splint, as in frac- 
ture of the elbow. 
Disease of the wrist is ordinarily treated by a plaster-of-Paris bandage, 
or by a leather splint, or even by simple carved wood splints applied in 
front and behind the joint. It is desirable in these cases, of course, to 
limit the action of the fingers. CHAPTER XVII. 
PLASTIC SURGERY 
Arpad G. Gerster, M. D 
History.—Among the various disciplines of the surgical art there 
is none more venerable and ancient than what is now termed plastic 
surgery. The sacred writings of India and the Ebert papyrus both 
mention rhinoplasty as a well-known procedure. Galen and Celsus, 
Antyllus and Paul the iEginete, all enter into the consideration of the 
subject. Malgaigne, in his introduction to Pa re’s Surgery, gives account 
of the family of Branca whose members were during the Middle Ages 
famous for their skilful restoration of lost noses. As the lopping off* of 
noses and ears was a favorite punitive measure during the Middle Ages, 
there was no lack of suitable material for the practice of rhinoplasty. 
The first systematic treatise on plastic surgery was published in 1597 
by Gaspar Tagliacozzi at Venice, remarkable for containing the first 
account of the so-called Italian method of rhinoplasty, in contradistinc- 
tion to the older Indian operation. The first Indian rhinoplasty was 
successfully done in London by Carpue in 1814, and shortly afterward 
by Dieffenbach in Germany, in whom we see the first enthusiastic culti- 
vator of modern plastic surgery. 
Definition.—In a general sense, the term “ plastic surgery ” com- 
prises all reparative measures, whether applied to the skin, tendons, 
nerves, or the skeleton of the human body. In its strict application, 
however, we understand by it those steps which aim at the reparation 
of defects and lesions of the shin only, and of the mucous membranes ad- 
joining the natural orifices. Under this now generally accepted definition 
Szymanovsky’s term of dermatoplasty coincides with the modern concep- 
tion of the plastic art. 
The Objects of Plastic Surg-ery are—The repair by living tissues 
of (1) congenital and acquired defects of the skin and adjoining mucous 
membranes; (2) of the consequences of simple lesions of continuity with- 
out defect; (3) of faulty arrangements of the orifices, congenital or 
acquired ; (4) of functional disturbances or of cosmetic blemishes due to 
the deposition of cicatricial tissue; (5) of perforations or fistulse estab- 
lishing abnormal communication between cavities or a cavity and the 
outer air. 
Whenever a defect is covered by living tissues taken from the body 
of the patient the process is termed autoplasty. Heteroplasty, on 
the other hand, is the operation wherein living tissues foreign to the 
bearer of the defect are employed. The transfer of a skin-flap from one 
individual to another constitutes heteroplasty. But where a defect of THE PURPOSES OF PLASTIC SURGERY. 
687 
any kind is corrected by the insertion of dead organic or inorganic 
matter the process cannot be termed truly a plastic one, as the element 
of organic cohesion is lacking. Nevertheless, some authors include these 
measures under the appellation of heteroplasty, though enthesis—insertion 
or coaptation—would be a better term. 
Thus the insertion of a plate of metal or celluloid into a cranial defect, the 
healing in of a metal frame for the support of a sunken nose, and, finally, the or- 
ganic enclosure of a celluloid ball into the scrotum after the removal of the testicle 
(Weir), all constitute enthetic rather than heteroplastic processes. Confusion in 
the terms will only be avoided by adhering to the postulate that a plastic opera- 
tion consists in the implantation of living tissue upon living tissue. 
General Principles Governing Technique.—(A) Transplanta- 
tion and Skin-grafting1.—The fact that a totally detached part of the 
body can form an organic union with another than the base from which 
it was severed, provided that it be adapted immediately and attached by 
suitable means, was known early enough to serve as a foundation for the 
older Indian method of rhinoplasty. Accounts that a severed nose-tip, 
a cut-off finger-tip, were reunited to their original sites are common 
enough not to admit of serious doubt. Nevertheless, the success of min- 
istration of this kind was so precarious and uncertain that—at least in 
Europe—no systematic plan of plastic repair was based upon this form 
of grafting. Knowing what important influence is exerted by the 
presence or absence of pyogenic infection upon the success of primary 
adhesion, we do not wonder that many or most of these extensive im- 
plantations turned out to be failures. Since we have learned to guard 
the efforts toward reunion of the living tissues against the deleterious 
influence of pathogenic parasites, we not only see minute particles, but 
extensive films, of epidermis become attached to a granulating surface. 
Finally, large detached flaps of skin, comprising its entire thickness, are 
transferred and made to become adherent with great certainty of success. 
Though the honor of having established a method of epidermatic grafting 
undoubtedly belongs to Reverdin, it is of much interest to know that Frank H. 
Hamilton performed as early as Jan. 21, 1854, at the Buffalo General Hospital, a 
successful transplantation of a rather extensive detached piece of skin upon the 
centre of a still more extensive ulcer of the leg. He described the characteristic 
border growth of the graft, and upon this based the conclusion that the graft may 
be considerably smaller than the defect to be healed. 
Reverdin’s first communication on epidermatic grafting was made to the 
Society of Surgery on the 8th of December, 1869, and immediately attracted 
universal attention, and received general confirmation. The fact that the deeper 
living portions of a detached piece of epidermis not only retained their vitality for 
a considerable time, but upon being apposed to a granulating surface were capable 
of proliferation, entering into an organic and permanent union with the base, was 
universally recognized. A further extension of the method came from Ollier,1 
who, instead of Reverdin’s minute morsels, successfully transplanted grafts of four, 
six, and eight square centimetres. But Ollier’s proposition did not meet with 
much favor, and remained barren. 
Interesting as Reverdin’s efforts were, they lacked practical utility, 
and epidermatic grafting in a generally useful form can be said to 
exist only since 1886, when Thiersch demonstrated that the cicatri- 
zation of a granulating surface or of a fresh wound, however extensive, 
could be brought about with much certainty by engrafting large films 
of epidermidcd material gained by the bold employment of a broad 
1 Bulletin de 1’ Acad, de Med. Parte, 1872, 2e Serie, p. 244. 688 
PLASTIC SURGERY. 
razor. Thiersch’s success would not have been possible without a reliable 
aseptic. (Thiersch’s method having been already described at con- 
siderable length on p. 277, Yol. I., detailed description will be omitted.) 
The entire raw surface of a wound can be thus covered with epider- 
matic grafts. The grafts are dressed with a shingling of rubber pro- 
tective washed in normal salt solution, which in its turn is covered by a 
liberal dressing of absorbent aseptic gauze held down snugly by a roller 
bandage. The dressings are not to be disturbed for three to five days. 
To avoid cicatricial keloid, McBurney recommends not to abandon too 
early the use of protective. The surface from which the graft was taken 
is covered with protective and the normal absorbent aseptic dressing, to 
be left undisturbed for a week. By that time the denuded surface is 
usually skinned over and firmly healed. 
The advantages of Thiersch’s method of transplantation are 
obvious : it does not sacrifice skin while procuring material for the repair 
of existing defects; the process is simple and easy; and success pretty 
certain. Its drawback is the circumstance that the grafts, however 
soundly attached, will not withstand much pressure and friction, such as 
is unavoidable in certain exposed localities, as, for instance, the elbow, 
knee, and heel. Renewed ulceration will destroy the grafts again and 
again, finally compelling the surgeon to resort to more radical measures. 
This serious defect of epidermatic transplantation has been remedied 
by the introduction of the bodily transplantation of large pieces of skin, 
comprising its entire thickness. 
To F. Krause belongs the honor of having demonstrated that the “older 
Indian method ” of transplantation, consisting of the fashioning of a new nose out 
of skin derived and totally detached from the nates of the patient, and further- 
more that Frank H. Hamilton’s procedures carried to a successful issue in an 
isolated case were capable of being formulated into a reliable and sound method 
of repair1 applicable in any situation of the integument. Asepsis, dry operating, 
and strict avoidance of all strong chemicals are imperative. 
The locality to which skin is to be transferred must be either a 
fresh wound, as would result from an extirpation of lupus or cancer, 
or, if it be occupied by a granulating ulcer, this must be converted into 
a fresh wound by paring or energetic scraping. After completed dis- 
infection with a sublimate solution, traces of this must be removed by 
irrigation with salt solution, and then the bleeding surface is covered and 
subjected to steady pressure by a dry sterilized compress of gauze. After 
this all the rest of the work must be done in a dry manner. It does not 
matter whether the preparatory paring and scraping leaves deeply de- 
pressed hollows or not, as experience has taught that the newly adherent 
flaps, though much depressed at first, become gradually raised to the nor- 
mal level by a copious subcutaneous deposit of connective tissue and 
even new-formed fat. 
The seat of the transplantation being thus prepared for the reception 
of the flap, the surgeon’s attention is now directed to the place whence 
the skin-flap is to be taken. The inner and anterior surface of the upper 
extremity, the anterior aspect of the thigh, and the trunk will furnish 
an abundant supply. In disinfecting the skin too much friction is to be 
avoided, according to Krause. 
1 Centralblatt fur Chirurgie, 1893, Beilage, p. 6. THE LOCALITY TO WHICH SKIN IS TO BE TRANSFERRED. 
689 
On the other hand, a transient hypenemia produced by friction or gentle 
flagellation is recommended by Hirscliberg, its prototype being found in the 
practice of our ancient Hindoo colleagues, who before excising a suitable 
skin-flap therefrom first administered with a slipper a smart spanking to the 
corresponding part of the nates. It was thought that a turgid and hyper- 
semic skin would better retain its vitality and would become adherent more 
readily. 
To facilitate the immediate suture of the defect produced by the 
raising of the flap, this should be fusiform in shape, and, if necessary, 
can extend the whole available length of the extremity, its width being 
limited only by the requirement of leaving behind enough skin to per- 
mit immediate closure of the wound by suture. In obese individuals 
this closure of the defect will be facilitated by the excision of some of 
the subcutaneous fat. The detachment of the flap is done as follows: 
The entire circumference of the flap to be raised is defined by an incision 
penetrating to the fascia. Then the lower angle of the flap is seized with 
a dry mouse-tooth forceps, and, being raised, its adhesions to the sub- 
cutaneous fat are divided with even strokes of the scalpel, the edge of 
the knife being directed toward the flap rather than against its base. The 
object of this rule is to remove the skin without any adherent fat. As 
soon as four or five inches of the flap are raised, the forceps is dropped, 
and the skin-flap is doubled upon itself, so as to bring in contact its raw 
surfaces, the surgeon’s fingers grasping the flap by its epidermidal sur- 
face. Thus unnecessary contact of the raw surface with fingers and 
instruments is avoided. Now the entire flap is detached, when it is seen 
to lose by shrinkage about one-third of its extent, and is immediately 
transferred to its new habitat, provided that hemorrhage of the base to 
which the flap is to be adapted has entirely ceased. To check hemorrhage 
torsion is preferable to ligature. 
As soon as the flap is in situ gentle elastic pressure is applied to expel inter- 
vening air, and in a few minutes a remarkable degree of adhesion develops between 
the newly-apposed surfaces, caused partly by the cementing effect of a very thin 
layer of blood, but mainly by atmospheric pressure. Now, and not before, are the 
edges of the flap trimmed off to fit. Sutures are not necessary, except where 
involuntary or uncontrollable reflex movements might dislodge the flap, as, for 
instance, near the mouth or on the face. When a gently compressive dressing can 
be well applied, this will be found sufficient. Extremities are to be immobilized 
by suitable splints. The manner of dressing recommended by Krause was found 
very defective, its changing so cumbersome and dangerous to the newly adherent 
flap that the present writer abandoned it in favor of the usual form of aseptic 
dressing; that is, the application of rubber protective, and over this of dry 
absorbent gauze compresses fastened by a roller bandage. The presence of the 
protective prevents adhesion and matting together of gauze and flap, and no dif- 
ficulty will be encountered in the safe and painless removal of this first dressing, 
more or less crusted with dried blood and otherwise adherent. 
The first change of dressings should take place on the fourth day. The appear- 
ance of the flap at this time is usually pale, sometimes bluish and livid, often cov- 
ered with a crop of bullae or vesicles, and very discouraging to the uninitiated. 
The vesicles should be opened with the scissors and the dressings renewed. By 
the seventh day a rosy hue begins to penetrate the superficial necrosed film of 
grayish epidermis, which can now be removed with a pair of forceps. Here and 
there small islands of shrunken dead skin can be recognized by the absence of 
hypersemia and turgor, indicative of circulation. The bulk of the flap will always 
survive and adhere, and it makes no difference whether the base to which the flap 
was transferred consist of muscle, fascia, connective tissue of any kind, periosteum, 
dura mater, or freshly exposed cortical or spongy bone. According to varying cir- 
cumstances, definitive cicatrization will require from three to six weeks. Sensation 690 
PLASTIC SURGERY. 
returns but very slowly. To replace hairy portions of lost skin—eyebrows, beard, 
and the hair—is feasible and easy. 
(B) Plastic by Gliding and by the Formation of Pediculated 
Flaps.—Though the scope of plastic surgery lias been considerably 
narrowed by the adoption of skin-grafting, the usefulness of the older 
methods stands nevertheless unimpaired in many exigencies. 
A defect acquired by disease, accident, or surgical operation can be 
repaired in two ways—either by gliding or by the formation and 
transference of the flap nourished through a pedicle. 
In the first case the gap is closed by distention or the stretching of skin adja- 
cent to the defect, which is rendered possible by a previous detachment of an ade- 
quate portion of skin from its underlying base—a process known by the name of 
“undermining.” No new defect is caused by this process, in which the elasticity 
and tensile property of the skin is utilized to cover an area larger than natu- 
rally pertains to the portions of skin used for this purpose. The method of 
gliding represents the simplest form of plastic operation, and deserves preference 
whenever practicable. Nutrition of the flaps is generally abundant on account of 
the usually broad attachments, and no new defect need be made to furnish plastic 
material. 
Where the method is impracticable we have to shape a flap detached 
on three sides of its circumference, and remaining attached at the fourth 
side—roughly speaking—when nutritive channels are preserved in what 
we term the pedicle. This flap being raised and transferred to the place 
which it is to invest, a defect is left at the site from which it was taken, 
which must be closed either by a subsidiary plastic operation, by gliding, 
or by another pedicled flap, or, finally, under favorable circumstances, 
can be made to heal under skin-grafts or by the process of granulation. 
Before entering into the consideration of strictly operative details 
certain general rules must be laid down, the observance of which is 
indispensable to success. 
First of all, strict aseptic or antiseptic precautions are imperative, especially where 
the nutritive channels are scanty. Where circulation is abundant—as, for instance, 
on the face—slight lapses from surgical cleanliness are easier overcome than else- 
where. Asepsis or antisepsis must be maintained after the operation so long as 
firm union is not secured; otherwise a late secondary infection may lead to the 
breaking down of recently formed adhesions. Secondly, haemostasis must be care- 
fully attended to, either by pressure, torsion, or ligature, before any sutures are put 
in. Occasionally, in well-nourished localities, suture may be used also as a means 
for stopping hemorrhage. But it is much safer first to staunch all hemorrhage, and 
then to suture the dry wound. Fine catgut is the best ligaturing material. On the 
head and face firm compression, exercised for ten minutes or so, will often be suf- 
ficient to check hemorrhage. The facial arteries have a strong tendency to retract, 
their cut ostia becoming soon plugged by thrombi. When hemorrhage is neglected 
more or less extensive haematomata are apt to develop, interposing themselves 
between the flap and its base, increasing tension, and retarding union, or finally 
serving as pabulum for infective germs. 
A useful flap must be first of all viable—that is, well nourished. It 
must contain not only the whole thickness of the skin, but also a portion 
of the subcutaneous connective tissue in which are distributed the nutrient 
vessels of the integument. The direction of the incisions must be in- 
fluenced by due regard to the course of the nutrient vessels, which ought 
to be preserved intact as far as possible. Flaps showing signs of arterial 
bleeding are well nourished ; those that turn chalky and (tale are less so, 
but may improve on the development of collateral circulation, when GLIDING AND FORMATION OF PEDICULATED FLAPS. 
691 
their turgor and rosy coloring will be regained. But the flap must 
remain well nourished even after fixation and after having been sub- 
jected to the necessary amount of stretching. 
While a pale flap may be of doubtful vitality, a blue or cyanosed flap is almost 
certain to decay. Cyanosis is the expression of the fact that, while arterial supply 
is preserved, the return circulation is embarrassed or suppressed. After a rear- 
rangement of sutures a moderate relaxation of tension by the reduction of the 
number of sutures or a straightening out of a too close twist of the pedicle, will have 
the desired effect. If not, the flap may be bled by one or more scarifying incisions; 
or, finally, even the complete division of the pedicle, converting the plastic into a 
case of skin-grafting, may be chosen rather than the certainty of gangrene by 
passive congestion. 
To fashion the flaps with due regard to nutrition and the avoidance 
of tension, they must be cut neither too large nor too small. If too 
large, there will be defective nutrition to the distal parts of the flap, 
with subsequent marginal necrosis. If too scanty, the sutures will 
exert so much tension as to cause acute anaemia, which will again result 
in disaster. It must be borne in mind that all flaps shrink very con- 
siderably after detachment, the minimum of shrinkage being one-third 
of the original extent. 
When all the preceding points have been well observed a correct 
adaptation by sutures will have to complete the work. 
As to material, silk, silver wire, silkworm gut or catgut, horsehair and kan- 
garoo tendon, may be selected, according to the exigencies of the locality. Silk- 
worm gut, silver wire, and silk are strong and unabsorbable, and deserve the pref- 
erence when temporary or lasting .tension will have to be sustained. Retention 
sutures should always be made of these materials, while sutures of simple coapta- 
tion, not subjected to any tension whatever, may be of catgut or horsehair or very 
fine silk. Buried sutures securing close contact of the deeper parts of a compli- 
cated wound—as, for instance, in the perineum—should always be made of 
absorbable material. 
As to the manner of suture, its form should be selected according to 
the necessities of each individual case. The interrupted suture will be 
found most generally adaptable, though continuous sutures may be found 
very useful at times for certain purposes. To produce a smooth and 
inconspicuous scar the adjustment of the edges of the wound will have 
to be very exact, the contact easy and complete. Where edges of 
unequal length are to be brought together an evenly and neatly dis- 
tributed “ shirring ” will have to come in. The pin suture, formerly 
very popular, has been all but abandoned. In its stead silkworm gut 
has come into much favor as a retentive suture material. 
When the suture is completed in a satisfactory manner the question 
of dressings will need attention. Where even a slight amount of exter- 
nal pressure might endanger the circulation of a precariously nourished 
flap, any external dressing of a bulky and confining character would be 
inadmissible ; in fact, it is best to leave the wound exposed, protecting 
its surface only by a generous dusting with iodoform powder or by a 
filmy shingling made of rubber-tissue protective. 
All sticky substances, as plasters and collodion, are to be avoided, as they only 
serve to irritate the patient and their retentive value is very problematic indeed. 
A properly made suture does not need the support of adhesive plaster slips or col- 
lodion, and a defective suture will not be saved by them. But where there is no 
objection to it a gently compressive aseptic dressing will be found a great comfort 
both to the patient and surgeon. The use of rubber protective should not now be 692 
PLASTIC SURGERY. 
oraitted, as thereby the adhesion of inspissated dressings to the newly united tissues 
will be prevented, and the change of dressings rendered easy and painless. 
As to drainage, only this need be said, that hollow spaces ought to be elim- 
inated by buried catgut sutures, and that by avoiding the use of too many, of 
too close, and of all unnecessary sutures sufficient gaps wTill be left for the ready 
escape of the first secretions. 
The time at which a plastic operation may be or ought to be 
undertaken will depend upon certain considerations, which may also 
receive some attention. When a congenital or acquired defect interferes 
with nutrition or any other important function, it is proper to operate at 
once. After excision of neoplasms, or the removal of lupous skin, imme- 
Fig. 335. 
Arrangement of the bundles of cutaneous fibres (Heitzmann). 
diate repair might be undertaken if the defect be not too extensive. But 
where the loss of integument is very great it is wise to let the wound be 
reduced in size by the process of cicatricial contraction before under- TRIANGULAR DEFECTS. 
693 
taking its plastic closure, as the delayed operation will be much easier 
than an immediate one. 
In the presence of syphilis it is the generally accepted rule, before under- 
taking the closure of existing defects, to eliminate first all active symptoms 
of the disease, especially in the vicinity of the field of operation. 
Plastic by sliding is appropriate only for the repair of defects of 
moderate extent, and only where the skin to be used is yielding and well 
nourished, even when subjected to considerable tension. It is desirable 
to give to the defect a simple and somewhat regular contour—as, for 
instance, that of a triangle, quadrangle, or an ellipse. Where, to do away 
with excessive tension, simple undermining of the flaps is insufficient, 
subsidiary relieving incisions are to be made. Their direction is deter- 
mined by the law of Sanger. This anatomist first described the remark- 
able systems of cutaneous fibres which determine the tensile properties 
of the skin. An incision laid parallel with the direction of a longitu- 
dinally arranged bundle of cutaneous fibres will not gap much, sometimes 
not at all, while if it is made transversely upon the main trend of the 
fibres, retraction will be very pronounced. Hence subsidiary or relieving 
incisions should always cross the course of the cutaneous fibres. Where 
several systems of fibres converge or enter into the formation of a whorl, 
semicircular or S-shaped incisions may be placed at some distance from 
the wound, and generally parallel with its longitudinal extent; or relief 
from tension may be secured by simply making an incision which is a 
prolongation and direct continuation of one or more sides of the defect. 
When a large defect is to be repaired, these two ways of relieving tension 
ought to be combined. 
Triangular Defects.—Small triangular defects can be closed by 
Fig. 336. 
Fig. 337. 
simply drawing together and suturing their angles. A small gap will 
remain uncovered in the centre, and can be left to cicatrize over by the 
Fig. 338. 
Fig. 339. 
process of granulation, or else can be covered with a skin-graft. The 
following diagrams will readily elucidate the technical principles govern- 694 
PLASTIC SURGERY. 
ing the repair of larger triangular defects. In Fig. 336 the flap is under- 
mined and detached from the base, and is glided over into the opposite 
angle of the defect in the direction of the arrow (Fig. 337). 
Fig. 340. 
Fig. 341. 
Fig. 342. 
Fig. 343. 
Fig. 344. 
In Fig. 344 the triangle on the right side is to heal by granulation; 
likewise the two small triangles in Fig. 346 ; or skin-grafting can be 
resorted to. 
Fig. 345. 
Fig. 346. 
Fig. 347. 
Fig. 348. 
Fig. 349. 
Fig. 350. 
All the preceding schemes are based upon methods devised by 
Dieffenbach. Bn row’s method of lateral triangles may, under cer- QUADRANGULAR DEFECTS. 
695 
tain circumstances, possess enough merit to warrant its adoption, but 
is open to the great objection that integument is unnecessarily sacrificed 
by it. For completeness’ sake it may be illustrated here. The skin en- 
Fig. 351. 
Fig. 352. 
,1 
closed in triangle ede, as in Figs. 351 and 352, is entirely excised ; then c 
is attached to a, and de becomes opposed to the line ce. Where the defect 
to be covered is large, Burow removes two triangles of skin, one from 
each side of the original defect, as illustrated by Figs. 353 and 354. 
Fig. 353. 
Fig. 354. 
Quadrangular Defects.—In quadrangular defects, as well as in 
triangular ones, if they be small and the skin yielding and well nour- 
Fig. 355, 
Fig. 356. 
Fig. 357. 
ished, closure can be effected by a gradual diminution of the four cor- 
ners. The small central gap necessarily persisting can be left to take 
care of itself or can be covered with a skin-graft (Fig. 355). 
Fig. 358. 
Fig. 359. 
When these expedients are insufficient, subsidiary incisions, aided by 
undermining or even the formation of quadrangular flaps and gliding, 696 
PLASTIC SURGERY. 
will have to be resorted to. In selecting the direction from which the 
flap is to be taken the tensile capacity of the skin should be carefully 
examined. Should the tension be excessive, a relieving incision, as 
indicated in Figs. 362 to 366, will diminish it. 
Fig. 360. 
Fig. 361. 
Fig. 362. 
Fig. 363. 
Fig. 364. 
Fig. 365. 
Fig. 366. 
Fig. 367. 
Fig. 368. 
Fig. 369. 
Fig. 370. 
In covering a very large defect the three preceding methods can be 
suitably combined (Figs. 368-370). 
Burow’s method is also applicable for the correction of quadrangular Q UADRA NO ULAR DEFECTS. 
697 
defects. In Fig. 371 the triangles a and 6 are excised before approxi 
mation of the flap. 
Fig. 371. 
Fig. 372. 
Fig. 373. 
Fig. 374. 
Fig. 375. 
Fig. 376. 
Fig. 377. 
Fig. 378. 
Fig. 379. 
Fig. 380. 
Figs. 377-382 represent Bruns’ and Langenbeck’s method for cover- 
ing trapezoid defects. 698 
PLASTIC SURGERY. 
Lanceolated, Elliptic, and Semilunar Defects.—Figs. 383-386 
represent Guerin’s method; Figs. 387, 388, Szymanovsky’s. 
Semilunar flaps (Fig. 389) were first proposed by O. Weber. 
Fig. 381. 
Fig. 382. 
Fig. 383. 
Fig. 384. 
Fig. 385. 
Fig. 386. 
Fig. 387. 
Fig. 388. 
Fig. 389. 
Fig. 390. 
Fig. 391. 
Fig. 392. 
When there is an abundance of integument, Burow’s excision of 
triangles may be successfully applied. In Fig. 393 the triangle a is 
excised; in Fig. 395, the triangles a and b. CIRCULAR AND IRREGULARLY-SHAPED DEFECTS. 
699 
In Figs. 394-400 the reader will see typical forms of plastic by 
transference of pediculated flaps. The form of the flap will have to be 
fashioned according to the shape of the defect which it is to cover. 
Fig. 393. 
Fig. 394. 
Fig. 395. 
Fig. 396. 
Fig. 397. 
Fig. 398. 
Fig. 399. 
Fig. 400. 
Fig. 401. 
Fig. 402. 
Fig. 403. 
Circular and Irregularly-shaped Defects.—Where it can be done 
without the sacrifice of too much integument, it is best to convert a cir- 
cular defect into a triangle or quadrangle, and then proceed according to 
the rules laid down for those. In the preceding figures the triangles 
marked a are excised. Should this not be feasible the flap method must 
be resorted to (Figs. 404 and 405). 700 
PLASTIC SURGERY. 
In dealing with a defect of a very irregular and complicated circum- 
ference it is best to make a study of the lines it is composed of, when it 
Fig. 404. 
Fig. 405. 
Fig. 406. 
Fig. 407. 
Fig. 408. 
will not be difficult to dissolve the figure into its simple components, 
such as triangles and quadrangles. These are then to be dealt with accord- 
ing to known rules, as in Figs. 406-408. CHAPTER XVIII. 
THE SURGICAL INJURIES AND DISEASES OF THE EYE 
AND ORBIT. 
Charles Stedman Bull, M. D. 
Prefatory Explanation.—Inasmuch as this is a work on Gen- 
eral Surgery, intended mainly and especially for students, it has been 
thought best to strictly confine this chapter on the Surgical Diseases of 
the Eye to such conditions as are commonly met with in general practice. 
The intention throughout has been to give the student such a knowledge 
of the frequent and superficial diseases and injuries of the eye as will 
enable him to recognize what he can safely deal with himself and what 
he would better turn over to the care of the skilled ophthalmic surgeon. 
Comparatively little mention has been made of operative technique, 
except in regard to operations on the eyelids, as it is the belief of the 
author that all operations on the eyeball would be better left to the care 
of the ophthalmic surgeon. 
ANOMALIES, INJURIES, AND DISEASES OF THE EYELID. 
Congenital Deformities of the Eyelids 
Epicanthis is a congenital malformation which consists in the pres- 
ence of crescentic folds of redundant skin which run downward from the 
Fig. 409. 
internal end of each eyebrow along the internal canthns and over the 
lachrymal sac, and often entirely conceal the caruncle. The deformity 
Excision of skin oyer bridge of nose for cure of epicanthis (Bull). 
701 702 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
varies in degree, is apt to be hereditary, and is often associated with 
defects in development of the eye and its adnexa, such as deficiency or 
absence of the levator palpebrse superioris, narrowness of the interpalpe- 
bral aperture, and marked flattening of the bones of the nose. In some 
cases the head is habitually thrown backward, as in cases of ptosis, in 
order that the patient may see objects below the horizontal meridian. 
When operative interference is indicated an elliptical piece of skin, with 
the long diameter vertical, should be excised from the root of the nose 
or glabella. The adjacent folds should then be freely undermined and 
loosened, and the lips of the wound closed by hare-lip or fine pin sutures. 
The result leaves a vertical scar in the median line. 
Coloboma of the eyelid is a congenital deformity of rare occurrence 
which usually involves the upper lid, and is sometimes associated with 
cleft palate, hare-lip, coloboma of the iris and choroid, and dermoid 
tumor of the cornea. To remedy this condition the edges of the colo- 
boma should be freshly pared and accurately brought together by fine 
twisted sutures passed through the tarsus, so that the lips of the fissure 
may be accurately united. 
Tumors of the Eyelids. 
Benign Tumors.—Under the head of benign tumors of the lids may 
be classed hordeolum, chalazion, xanthelasma, molluscum contagiosum, 
fibroma molluscum, warts, cysts, and angeiomata. 
Hordeolum, or stye, is a phlegmonous inflammation of one of Zeiss’ 
glands at the ciliary margin of the lid, where it forms a painful circum- 
scribed swelling. It is apt to be associated with conjunctivitis or mar- 
ginal blepharitis, and corresponds to a small boil. The growth may 
sometimes be checked by the application of iced-alum solution (one 
Fig. 410. 
Fig. 411. 
Chalazion (seen from within) (Mackenzie). 
drachm to the pint), but the process generally suppurates and points, and 
should be punctured at an early date, and then hot fomentations should 
be applied until the pain and swelling have subsided. 
Chalazion is a chronic cystoid distention of one or more of the 
Chalazion (Dalrymple). TUMORS OF THE EYELIDS. 
703 
Meibomian glands. It develops very slowly, is usually painless, and 
rarely occurs singly. It may develop in any portion of a Meibomian 
gland, and involve the whole gland or several adjoining glands. As it 
grows it causes a yellowish projection on the conjunctival surface, and 
if of any size soon becomes visible through the skin. 
The contents may be glairy mucus or a cheesy material, or a mixture 
of granulation-tissue and giant cells. When the chalazion occurs at the 
margin of the lid it may be opened through the lid margin with a small 
scalpel, the contents squeezed out, and the interior scraped with a small 
spoor or spatula. If, however, the cyst be of any size or situated away 
from the lid margin, the lid should be clamped by lid-forceps, of which 
one blade is of horn or steel, to lessen hemorrhage, and an incision 
made horizontally through the skin over the chalazion, the fibres of the 
orbicularis pushed aside, and the entire cyst carefully dissected out. The 
Wound in the skin is then to be closed by two or three delicate sutures. 
Xanthelasma is a flat tumor of a dirty-yellow color projecting slightly 
above the skin of the lid, and found most frequently in the vicinity of 
the inner canthus. It consists in a hyperplasia and fatty metamorphosis 
of the connective-tissue cells of the skin. It is apt to occur in groups, 
and the patches may be excised and the wound closed by dissecting free 
the surrounding skin and bringing the edges together with sutures. 
Molluscum contagiosum is a small rounded tumor with flattened surface and an 
umbilicated depression at the centre, from which on pressure exudes a whitish fluid. 
Fibroma molluscum is a small, hard, circumscribed tumor of the skin with a 
pedicle, and consists of finely fibrillated connective tissue. Both these growths may 
be readily removed by excision. 
Warts and cutaneous horns are sometimes met with on the edge of the lids, and 
may readily be excised. 
Cysts of the eyelids are either of the atheromatous or dermoid character, and 
closely resemble similar tumors in other parts of the body. Dermoid cysts are 
always congenital, sometimes grow to an enormous size, and are often connected 
with similar growths in the orbit, and under such circumstances require great care 
in their removal. True fibromata are rarely met with in the eyelid. They are sit- 
uated in the submucous connective tissue, and are apt to assume a cartilaginous 
character. They may be readily excised. True lipomata are of infrequent occur- 
rence in the lids, and may be easily recognized by their smooth, circumscribed, 
lobulated form and their firmness and elasticity. They grow very slowly and can 
be readily removed. Adenoma, fibrillary neuroma, and cysticerci have been occa- 
sionally reported, but they are so extremely rare in this locality that they require 
no further consideration. 
Angeiomata, or vascular tumors of the eyelids, are met with under two forms, 
teleangiectatic and cavernous tumors. They are always congenital, but are apt to 
develop very rapidly after birth, and hence should be removed as early as possible. 
Teleangiectases appear as bright-red spots in the skin of the lid. If they are small, 
they should be cauterized by the thermo-cautery or galvano-cautery; if they are 
large, they may be cauterized along a number of lines instead of over their whole 
surface, and the resulting cicatrization obliterates the intervening vessels. 
Cavernous tumors lie beneath the skin, push it forward, and give it a bluish color. 
They consist of a convoluted mass of large blood-vessels which can be felt beneath 
the skin. In these cases the best results seem to be gained by electrolysis, though 
in cases of moderate size they may be excised if care be taken to use a large lid- 
clamp. These angeiomata are aiso apt to be connected with similar vascular 
tumors in the orbit, and in such cases excision would be a doubtful procedure. 
Amyloid disease of the tarsus as a primary lesion is a very rare 
occurrence. The symptoms are—enormous thickening and elongation of 
the lids, which are very hard and cannot be everted, the absence of all signs 704 
INJURIES AND DISEASES OF TIIE EYE AND ORBIT. 
of inflammation and of pain, and the steady growth of the disease, which 
has been known to involve the orbit and eventually extend to the brain. 
Treatment here seems to be of no avail. 
Lupus as a primary lesion in the eyelids is very rare, but by no means 
uncommon as a secondary growth extending from the nose or cheek. In 
the earlier stage it should be cauterized, but when more advanced it 
should be excised and the defect in the lid replaced by some form of 
blepharoplasty. 
Lepra, or elephantiasis, in the countries where this disease is endemic 
has been frequently observed, nodules forming beneath the skin as the first 
symptom of the disease. These should be extirpated before ulceration has 
begun, for after this all treatment is useless. 
Malignant Tumors of the Eyelids.—The only forms of malignant 
disease which occur primarily in the eyelids are carcinoma and sarcoma, 
and the latter is rare. The usual form met with in the eyelids is epi- 
thelioma, and it usually develops in the skin near the ciliary margin, and 
by preference in the lower lid near the outer canthus. 
It appears as a small, circumscribed, slightly elevated induration at the edge 
of the lid, looking like a small wart. The surface is sometimes rough and scaly. 
It may remain in this condition unchanged for an indefinite period, or may show 
a tendency to ulcerate. It slowly creeps along the edge of the lid, its surface 
behind becoming broken and excoriated and covered by a thin, grayish-yellow 
discharge, which hardens into crusts. The tumor spreads slowly in circumference 
and depth, the skin around it becomes thickened and swollen, and the pain, at first 
slight, may become severe. The lymphatic nodes in the vicinity may or may not 
become enlarged. If the growth be allowed to extend, it eventually involves the 
conjunctiva of the lid and eyeball, the orbital tissue, and the eye itself. 
The progress is always very slow, and if left to itself, the prognosis is un- 
favorable. 
Treatment.—So soon as the growth shows a tendency to spread, it 
must be removed at once by excision, through perfectly healthy tissue, 
from ciliary margin to cul-de-sac and through the entire thickness of 
the lid, and the gap in the lid made by its removal filled in by some 
form of blepharoplasty. 
Rodent ulcer is a clinical form of epithelioma which not infrequently 
occurs on the eyelids. It takes the form of a shallow ulcer with uneven 
floor and irregular hard walls. The infiltration of the walls of the ulcer 
is the characteristic symptom. It is a form of epithelial carcinoma, and 
the ulcer advances in one direction while it cicatrizes at the opposite end. 
Its progress is extremely slow. 
Sarcoma originating in the eyelid is a rare affection, though an 
orbital sarcoma frequently extends to the lids. It develops in the con- 
nective-tissue portion of the lids, especially the tarsus, and is often 
deeply pigmented (melano-sarcoma). Primary sarcoma of the lid occurs 
mainly in childhood or youth, beginning as an elastic swelling beneath 
the skin, which grows rapidly and soon infiltrates the interstitial tissue 
of the orbicular muscle. It is prone to extend to the orbital tissue, 
and thence to the eyeball. 
Affections of the Muscles of the Eyelids. 
Spasm of the orbicularis muscle may be both tonic and clonic, the 
latter being the more important. It is sometimes called facial tic, is AFFECTIONS OF THE MUSCLES OF THE EYELIDS. 
705 
paroxysmal and very painful, and is sometimes accompanied by points 
of tenderness over the supraorbital or infraorbital nerves. The cause 
is often of cerebral origin. The intensity of the symptoms can some- 
times be relieved by correcting refractive and other muscular errors by 
glasses. If the cause be peripheral, relief is gained, and sometimes a 
cure established, by continuous counter-irritation or neurotomy, or by 
exsection of a piece of the offending nerve. 
Paralysis of the orbicularis muscle, or lagophthalmos, is caused by 
some lesion of the seventh nerve, which may be central, or lie in the 
course of the nerve, or be peripheral. When of long duration it is 
usually accompanied by ulceration and even abscess of the cornea. 
The treatment indicated is such as would be called for in any case 
of facial paralysis. If the cornea become affected, it may be necessary 
to shorten the palpebral aperture by tarsorrhaphy. This consists in 
paring the edges of the lids for a distance of ten or fifteen millimetres 
near the outer canthus, and then uniting them by sutures, which should 
be left in place for a week. 
Ptosis, or Paralysis of the Levator Palpebrce Superiors.—Ptosis is 
the name given to that condition in which the upper lid droops or hangs 
down over the eye, so that the interpalpebral aperture is narrowed and 
the cornea is more or less concealed from view. True ptosis is due to 
paralysis of the levator muscle of the upper lid, and is usually asso- 
ciated with paralysis of other branches of the third nerve, though it 
may exist alone. It may be partial or complete. In the former the lid 
may be slightly raised by voluntary action, and this is assisted by the 
action of the frontalis muscle, and the forehead comes to have a 
wrinkled appearance. 
Etiology.—Its cause may be either peripheral or central. If the 
latter, some of the other branches of the third nerve are usually involved, 
and sometimes all. If the former, it is due to pressure, on the branch 
of the third nerve going to the levator, by an exostosis or small tumor 
somewhere at the base of the skull or near the apex of the orbit, and in 
very rare instances by periostitis at the bottom of the orbit. Still, cases 
of isolated ptosis, without other signs of oculo-motor paralysis, are fre- 
quently caused by central disease. 
A difference should here be recognized between congenital and acquired ptosis. 
The former is not caused by paralysis of the nerve, but is due to the arrest of de- 
velopment or entire absence of the levator muscle. It usually involves both sides, 
and is often transmitted by heredity. 
A form of spurious ptosis is often met with in chronic trachoma or after puru- 
lent conjunctivitis, in which the lid droops by its own weight after the disease which 
caused it has subsided. The lid can be raised, but not to its full height. Here 
the muscle is not paralyzed, but is hindered in its action by the abnormal thick- 
ening of the lid. 
Treatment.—If the ptosis be of recent occurrence, we should attempt 
its cure bv the internal administration of potassium iodide or mercurials, 
or both, and by the application of the galvanic current to the muscle, 
one pole being placed behind the ear and the other over the closed lids. 
If in the course of two or three months there be no improvement, we 
must resort to surgical interference. 
A great many surgical operations have been suggested for the relief of ptosis, 
but most of them are only partially successful. If the ptosis be only slight and par- 706 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
tial, VonGraefe’s operation may perhaps suffice. A transverse incision is made in 
the skin, 5 mm. above the border of the Lid and parallel to it, from one end of the 
lid to the other; the lips of this wound are separated and the fibres of the orbicu- 
laris muscle are extensively exsected. A strip of skin may also be excised. The 
wound is then closed by sutures, which are passed not only through the skin, but 
also through the orbicularis fibres. The effect of this operation is to cause a sub- 
cutaneous shortening of the upper lid, weaken the action of the orbicularis, and 
thus assist that of the levator. 
In all cases of marked paralysis of the levator, resort must be had to some 
method of operating which will bring the lid more or less directly in connection 
with the fibres of the frontalis muscle. All attempts hitherto made to advance the 
tendon of the levator muscle have proved more or less unsuccessful. The operation 
which perhaps gives the best results was devised by De Wecker, and is done in the 
following manner: A portion of skin and muscular fibre is removed from the upper 
half of the tarsus, its breadth depending on the fulness of the lid. A strong 
Fig. 412. 
thread is entered above the brow, pushed beneath it and the skin of the lid, 
keeping close to the tarso-orbital fascia, and is brought out at the upper edge of 
the wound; this passes over the muscular fibres, then under the skin and muscle 
at the lower edge of the wound, emerges, and then passes transversely along for 
5 mm. over the skin, and then is carried in a reverse direction over the same course. 
Two such sutures are introduced. They are tied over a piece of rubber tubing, 
and tightened from time to time as they become loose. The wound is thus pulled 
together, and as the sutures cut through the tissues scars are formed which hold 
the lid up permanently. 
De Wecker’s operation for ptosis (De Wecker). 
Entropion. 
Th is is the term employed to describe a condition in which the entire 
edge of the lid is turned inward, so that not only the cilia, but the skin- 
edge of the lid, is brought in contact with the cornea. It is one of the 
sequelae of chronic trachoma, and is generally due to the cicatricial con- 
tracting tendencies of that disease. In this condition the lashes are 
inverted, the palpebral aperture is shortened, the tarsus is thickened and 
incurvated, and the lids hug the eyeball closely. The results are ulcer- 
ation, vascularity, and opacity of the cornea, and in bad cases a tendency 
to the development of a staphyloma. 
Besides this form of entropion, there are two other varieties, the senile and the 
spastic. Senile entropion comes from relaxation of the tissues, the skin becoming 
folded and drooping, and the action of the orbicularis aids in the effect. Spastic 
entropion is met with in cases of chronic keratitis and other superficial inflam- 
matory processes. 
Treatment.—The essential cause of ordinary entropion is deformity 
of the tarsus, and all operations must be adapted to modify and correct ENTROPION. 
707 
this deformity. The operations of Arlt, Jaesche, and many others begin 
by splitting the lid vertically into two layers, an anterior and a posterior, 
for a distance of 3 to 4 mm. from the ciliary margin. A horizontal incision 
is then made through the skin of the lid throughout its entire length, 
parallel to and a short distance above the ciliary margin. The ends 
of this incision are then united by a curved 
incision through the skin on a level with 
the upper edge of the tarsus, and the en- 
closed strip of skin is then excised. The 
horizontal bridge of skin is then carefully 
separated from the underlying muscle, 
and, remaining attached at its extremities, 
is drawn up and sutured to the upper skin 
margin of the denuded space (Fig. 413). 
Fig. 413. 
Where no serious deformity of the tarsus 
exists this method of transplantation of the cilia 
serves an excellent purpose. If, however, the 
abnormal curvature of the tarsus be marked, this 
method will not suffice, and we must resort to the 
excision of a horizontal wedge-shaped piece of 
the tarsus or to its entire removal. A less rad- 
ical procedure is the operation devised by Dr. 
John Green, the main feature of which consists 
in a horizontal incision which is made through 
the entire thickness of the tarsus on its conjunc- 
tival side, parallel to the lid border and about 
2 mm. above it. A full description of this 
method would be too long for this place, and 
may be found in any complete work on ophthalmology. Hotz’s operation is per- 
formed by seizing the lid at its middle between the thumb and finger, keeping 
it on the stretch, and making a horizontal incision through the skin from one end 
to the other, about 2 mm. above the ciliary margin. When the lid is released the 
skin contracts, causing the upper edge of the incision to become curvilinear. The 
muscular fibres are then carefully pushed away from the upper third of the tarsus. 
Three or four sutures are next carried through the skin at the lower margin of the 
wound, the needles being again inserted through the outer fibres of the tarsus at 
Jaesche-Arlt operation on the upper 
eyelid (Arlt). 
Fig. 414. 
Graefe’s operation for entropion (Wells). 
its upper part, and the sutures passed through the tarso-orbital fascia and brought 
out through the skin at the upper edge of the wound. The stitches should be 
removed on the second day. 
The senile variety of entropion may generally be relieved by the application of 
contractile collodion on the skin surface or by the excision of a properly propor- 
tioned piece of skin, and bringing the edges of the horizontal wound together by 
sutures. 708 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
Spastic entropion is more obstinate in resisting treatment, and may generally 
be relieved by an operation devised by Von Graefe, which consists in removing a 
triangular piece of skin from the lid, the base being parallel to and just above the 
lid margin in the upper lid or below it in the lower lid, and the apex pointing 
upward or downward as the case may be, and then closing the wound by sutures 
(Fig. 414). 
This is the term applied to eversion of the lid, with exposure of the 
conjunctival surface, and the condition may be either partial or complete 
according as a part or the whole of the lid is involved. It may be 
either acute or chronic. 
Acute ectropion is usually muscular in character, and is met with in 
children with conjunctivitis and in diseases of the cornea with blepharo- 
spasm, in which the lids sometimes become everted and remain so until 
replaced. Another form of muscular ectropion is met with in facial 
paralysis. 
Chronic ectropion is sometimes seen in old persons with relaxed lids, 
with or without conjunctivitis. 
The commonest causes are wounds, both incised and lacerated; 
burns with subsequent cicatricial contraction; chronic inflammation of 
the ciliary margins of the lids; ulceration of the lids, such as lupus; 
tuberculous and syphilitic nodules; and caries of the orbital margins. 
The lower lid is more frequently involved than the upper lid. 
The treatment will be considered under the general head of 
Blepharoplasty, or Operations upon the Eyelids. 
Distichiasis is a term applied to that condition in which there is a 
double row of cilia on the edge of the lid, one of which is developed 
from the intermarginal part, close to the openings of the Meibomian 
glands, and the cilia in which sweep the eyeball. The condition is 
usually caused by chronic marginal blepharitis and blepharo-adenitis, 
chronic granular conjunctivitis or trachoma, and burns. In rare 
instances it is congenital. The rubbing of the cilia against the cornea 
produces constant irritation, and may give rise to ulceration. 
Trichiasis is a condition which differs from distichiasis in the irreg- 
ular position and shape of the cilia which touch the eyeball. The latter 
may be partially or entirely inverted and in different directions. There 
may be thickening of the tarsal border, but the tarsus itself is not altered 
much in its curvature, and this makes the difference between trichiasis 
and entropion. 
The causes of trichiasis are the same as for distichiasis. 
The TREATMENT for distichiasis and trichiasis, unconnected with 
entropion, consists of epilation ; snaring the wild hairs with the loop 
of a thread ; destruction by hot needles or by electrolysis; and excision 
of the follicles. 
Ectropion. 
Epilation gives only temporary relief, and must be repeated every few weeks. 
Ensnaring the laslies in a loop of thread was devised by Snellen, and consists 
in introducing a needle, through the eye of which both ends of a fine silk thread 
have been passed, in the edge of the lid near the displaced hair, and bringing it 
out through the skin some distance from the lid margin, and as the loop is drawn 
toward the base of the hair the latter is put within the loop and drawn up into the 
substance of the lid. 
Destruction of the hair-follicle by electrolysis is very useful for individual hairs. 
The needle which is pushed into the follicle must be connected with the negative ECTROPION. 
709 
pole of a constant battery, and the current should be passed for a minute. The 
positive pole may be placed on the temple or cheek. Two or three cells will 
furnish sufficient current. 
Excision of the follicles is done by taking out a rectangular portion of the tarsus, 
without injuring the Meibomian follicles, according to the plan of Anagnostakis. 
The overlying skin is dissected up in a little flap, and this may be extended upward, 
and after the excision of the piece of tarsus the flap is dragged down, its tip is cut 
off, and the flap is turned in to cover the lid border, and held in place by a suture 
at each angle. 
Blepharoplasty is the general term applied to the surgical proce- 
dures which are undertaken for the relief of ectropion and similar con- 
ditions of the lids, which require the resto- 
ration of the lids to their normal position 
or the formation of a new lid, in whole 
or in part, from the neighboring tissues. 
Ectropion of a moderate degree, in- 
volving only part of the lower lid, may 
generally be relieved by the excision of 
a piece of conjunctiva or of a V-shaped 
piece from the entire thickness of the lid, 
and then carefully bringing together the 
raw edges by hare-lip pin sutures. Com- 
plete ectropion of the entire lid, due to ex- 
tensive scars or other causes, requires a 
much more extensive operation (Figs. 415 and 416). In ectropion of 
the lower lid Arlt’s operation gives excellent results. A triangle 
is formed by the incisions ab and be, and a piece from 2 to 3 mm. 
deep is removed. The triangular flap is loosened as far as neces- 
Fig. 415. 
Arlt’s operation for ectropion (Arlt). 
Fig. 416. 
Richet’s operation for ectropion (Arlt), 
sary, and the wound is sutured so that c comes up to d, and the side of 
the flap marked 6c lies against the skin-wound, cd. The gap left by the 
closing of the flap is to be closed by hare-lip pins. 
Kichet’s operation for ectropion of the lower lid is as follows (Fig. 416): 
The cicatrix is excised by three curvilinear incisions—one, BA, at the orbital 
margin below the scar; one, CA, between the scar and the margin of the lid; and 
one, BE, which, starting on the upper lid, is carried in a curve down upon the 
cheek so as to reach the outer end of the second incision at B. The scar is dis- 
sected out and the lid is replaced and held in position by temporary sutures pass- 710 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
ing through the margins of both lids. A fourth curved incision, FG, starting 
from the junction of the upper two-thirds with the lower third of the last incision 
and extending upward on the temple, is next made. The last flap, DFG, is stitched 
into the defect made by excision of the scar, thus bringing F to A. The lower flap, 
ABE, is loosened and pulled up to cover the gap left in the skin of the temple. 
Ftg. 417. 
Fig. 418. 
Operation for ectropion of lower lid (Richet). 
Fig. 419. 
Fricke’s method of blepharoplasty (Arlt). 
Fro. 420. 
Utilization of flap from temple (Stellwag). 
True blepharoplasty consists in making a new lid, and numerous ope- 
rations have been devised for the purpose. The new flap may be taken 
from the temple (Fig. 420) or forehead or side of the nose or cheek, or it 
may be transplanted from some distant portion of the body without a ECTROPION. 
711 
pedicle, as from the side of the cheek or anterior surface of the forearm. 
Such an operation becomes necessary after the removal of epitheliomata 
or other tumors. These flap operations may be briefly divided into 
three groups. 
Fig. 422. 
Fig. 421. 
Dieffenbach’s method of blepharoplasty 
(Arlt). 
Arlt’s method when a portion of the eyelid is 
to he sacrificed (Arlt). 
(1) Those in which a somewhat tongue-shaped flap is carried in from 
the side of the nose for repair of the lower lid or from the temple for 
restoration of the upper lid (Fig. 419). 
Fra. 423. 
Fig. 424. 
Utilization of quadrangular flap from cheek (Stellwag) 
(2) Those in which a quadrilateral flap is moved over or shifted, so 
as to cover in a triangular defect in the lower lid (Figs. 421-424). 712 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
(3) Those in which the surrounding skin is extensively incised, 
undermined, and dissected up, and the flaps thus made are drawn or slid 
together so as to cover the space to be filled. The latter is especially 
Fig. 425. 
Knapp’s method of blepharoplasty (Knapp). 
useful in cases of neoplasms of the lower lid, and the best method is that 
devised by Knapp (Fig. 425). 
In the repair of lesions about the inner halves of the lids, or in cases where 
there is no skin available for flaps either on the forehead or temple or outer part 
of the cheek, Dr. H. D. Noyes makes use of a naso-buccal flap in which the incis- 
ions are made down the side of the nose and cheek as far as the upper lip, the free 
end being below and the attached end or base above. The incisions are so made 
as to include vessels which come from the supraorbital, ethmoidal, and nasal 
branches of the orbital arteries, and also some branches from the other side of the 
median line, by making the incision obliquely across the nose. When this flap is 
twisted on its base upward and placed in position, there is left a large gap in the 
face, which is filled by sliding the cheek in toward the median line and uniting 
the edge by pins and figure-of-8 sutures. 
Diseases of the Conjunctiva. 
In all forms of conjunctivitis there are one or two rules of treatment 
which the student and practitioner would do well to remember. The 
first is always to use cold or even iced fomentations, unless there is dis- 
tinct and urgent need to hasten suppuration. Another is never to use 
atropine unless the cornea shows evidences of becoming involved. The 
tendency among most physicians is to use atropine in all forms of in- 
flammatory affections of the eye, and to use warm or hot fomentations in 
conjunctivitis; and both these tendencies should be frowned down and 
prevented as far as possible. 
But three forms of conjunctivitis will be considered in this chapter, 
and these very briefly—viz. Purulent Ophthalmia, Diphtheritic Conjunc- 
tivitis, and Chronic Granular Conjunctivitis, or Trachoma. 
Purulent Ophthalmia.—Under this head are included the purulent 
conjunctivitis of new-born infants and the purulent inflammation of the 
adult, both non-specific and gonorrhoeal. 
The symptoms in all are the same, and differ only in intensity. There 
are marked injection of the palpebral and ocular conjunctiva; chemosis 
of the conjunctiva; swelling; infiltration and discoloration of the lids; 
a purulent discharge, more or less profuse, which glues the lids together; DISEASES OF THE CONJUNCTIVA. 
713 
heat; and pain, which at times is very severe. The lids become even 
purple in line, and so hard from infiltration that they cannot be moved. 
In bad cases the cornea soon becomes hazy, and then rapidly opaque, 
from strangulation of its nutrient blood-vessels and lymphatics by the 
great pressure. In the adult the symptoms are all worse than in oph- 
thalmia neonatorum, and in gonorrhoeal conjunctivitis the symptoms are 
more intense and the course of the disease much more rapid and destruc- 
tive than in the non-specific form. 
The prognosis in all forms of the disease is unfavorable, but is much 
better in ophthalmia neonatorum than in the other forms. While it may 
be confined to one eye, it generally involves both. The great danger is 
suppuration of the cornea with consequent loss of sight. 
Treatment.—In ophthalmia neonatorum cold applications should be 
made by cloths soaked in cold water and laid upon the closed lids, and 
frequently changed. Frequent irrigation of the culs-de-sac with cold 
bichloride solution (1 :10,000) or cold boric-acid solution, and the appli- 
cation of a solution of silver nitrate to the everted lids (gr. i-v to the 
ounce), several times daily, are indicated. 
In the purulent conjunctivitis of older 
children or of adults the application of cold 
through the medium of iced cloths, laid 
upon a block of ice and then applied to the 
lids and changed once a minute, should be 
insisted upon, and the irrigation of the 
culs-de-sac should be increased in frequency 
according to the amount of secretion. If 
the lids are very hard and tense, it may be 
necessary to perform canthotomy by divid- 
ing the external canthus with a strong pair 
of blunt-pointed scissors, and the severing 
of the external canthal ligament, so as to 
diminish the pressure on the eyeball. As 
soon as the lids can be everted they must be 
cauterized with a strong solution of silver 
nitrate (gr. x-xj), until the discharge ceases 
or becomes thin and ichorous, when it may 
be discontinued. 
Fig. 426. 
Diphtheritic Conjunctivitis.—Though the disease sometimes occurs 
alone, it is usually connected with diphtheritic inflammation in the nose 
and fauces. The external symptoms resemble those of purulent conjunc- 
tivitis, except that there is more marked infiltration of the tissues of the 
lids and much less secretion until the purulent stage is reached. If the 
lids can be everted, there is no distinct membrane visible, but the con- 
junctiva and tarsus seem enormously thickened, present a bloodless 
appearance, and look like brawn, and the same condition exists in the 
ocular conjunctiva. The cornea rapidly becomes opaque and necrotic. 
In these cases it is sometimes necessary to discontinue the cold applica- 
tions and resort to hot fomentations in order to hasten the suppurative 
stage, and thus, if possible, save the cornea by a reopening of the nutrient 
blood-vessels. 
When the suppurative stage has been reached the treatment is the 
same in all respects as for purulent conjunctivitis. 
The prognosis is always unfavorable, most of the eyes so affected 
being lost through destruction of the cornea. 
Ophthalmia neonatorum (Dalrymple).  INJURIES AND DISEASES OF THE EYE AND ORBIT. 
714 
Granular Conjunctivitis, or Trachoma.—This is a chronic inflam- 
mation of the conjunctiva which originates by infection and produces an 
infectious purulent secretion. The conjunctiva becomes very much 
thickened, the papillae hypertrophied, and a peculiar kind of granule is 
developed, mainly in the tarsal conjunctiva, but also in the fornix and 
occasionally in the ocular conjunctiva. It is one of the most frequent 
forms of eye disease which the surgeon is 
called upon to treat. It exists in two 
forms. The first form consists in the 
development of papillae on the surface of 
the conjunctiva tarsi, without at first any 
thickening of the conjunctiva. The second 
form is characterized by the presence of 
the trachoma granules, which are gray or 
yellow, translucent, round bodies beneath 
the conjunctiva. They are sometimes 
distinctly gelatinous, and have received 
the name of “frog-spawn” granulations, 
or “sago grains.” They are found mainly 
in the fornix or retrotarsal fold, and are 
sometimes arranged in longitudinal rows. These two forms sometimes 
occur separately, but are more often found together. 
Symptoms.—These are photophobia, lachrymation, impaired vision, 
and a sticking together of the edges of the lids, dependent upon the 
amount of secretion. If the case be an old one, there are either ulcers 
of the cornea or a condition known as pannus, which is a superficial 
keratitis, with or without the development of blood-vessels on the 
cornea, with hypertrophy of the epithelial layers, and opacity of the 
whole surface. 
The SEQUELAE of trachoma are trichiasis or distichiasis, which is a 
faulty arrangement of the cilia; entropion, posterior symblepharon, 
xerosis of the conjunctiva, and opacities of the cornea (Fig. 428). 
Fig. 427. 
Conjunctiva of upper lid in chronic 
granular conjunctivitis (Arlt). 
Fig. 428. 
Section of conjunctiva in granular conjunctivitis (Fuchs). 
Treatment.—During the last few years attempts have been made 
to shorten the duration of the treatment of this most chronic disease by 
various surgical procedures. Of these it is only necessary to mention 
one, the so-called method of expression. This consists in gently scari- 
fying the conjunctiva over the masses of trachoma granules, and then 
holding the everted lid firmly by one end, applying Noyes’ forceps or PTERYGIUM. 
715 
Knapp’s roller forceps to the opened follicles, and by compression 
squeezing out the contents of these follicles from one end of the lid to 
the other. As soon as one row is emptied the forceps should be applied 
to another row, and this should be kept up until all the follicles have 
been emptied of their contents. The cul-de-sac and lids are then washed 
clean with a bichloride solution (1 : 5000) and cold dressings applied, 
which must be frequently removed. The conjunctival surface is subse- 
quently treated with astringent solution or by touching it with alum or 
sulphate of copper in crystal as long as any roughness or secretion 
appears. 
The apparent advantage of this treatment over the old daily cauterization of 
the granulations appears to lie in shortening the duration of the disease. But 
experience has taught us that every process for directly destroying the granulations 
renders the shrinking of the conjunctiva only so much the greater, and the occur- 
rence of the unfortunate sequelae in the lids the more pronounced. Many surgeons 
therefore prefer to cauterize the granulations daily with a crystal of sulphate of 
copper or with strong solutions of nitrate of silver (gr. xx to xl), and apply cold 
applications for an hour to the closed lids; and this treatment is to be continued 
with modifications until the granulations have disappeared. 
Pterygium. 
A pterygium is a triangular thickening or hypertrophy of a fold of 
the ocular conjunctiva, which grows from the inner or outer canthus 
toward the cornea and extends for a varying distance upon the cornea. 
The apex of the triangle is on the cornea and the base toward the can- 
thus. It may be very thin and delicate, containing but few blood-ves- 
sels, and is then known as pterygium tenue, or it may be thick, opaque, 
and vascular, and is then termed pterygium crassum, both forms being 
simply different stages of the same growth (Fig. 429). 
Its name is derived from the supposed resemblance in shape and texture to the 
wing of a small insect. It is most frequently found on the nasal side of the cornea, 
and it is occasionally met with on both sides of the cornea in the same eye. The 
apex of the growth is usually rounded and firmly adherent to the cornea, and the 
fan-like base spreads out and becomes merged with the conjunctiva, while when on 
the nasal side the plica semilunaris is entirely lost in the growth. Beyond the 
limbus the edges of the pterygium are rounded and not so adherent to the subcon- 
junctival tissue, and a probe may be pushed beneath them for some distance 
(Fig. 430). 
A pterygium grows very slowly, with or without symptoms of irri- 
tation, toward the centre of the cornea, which it only reaches in excep- 
tional cases. It may remain stationary for years, being at times subject 
to inflammatory attacks. If it remain stationary, it grows thinner 
and lighter in color from disappearance of its vessels, and may event- 
ually be converted into a thin, tendinous membrane. It produces no 
injurious results until its apex begins to involve the pupillary area 
of the cornea, when the vision becomes affected, and the visual de- 
fect increases in proportion as the apex of the growth approaches 
the centre of the cornea. An additional annoyance produced by a 
pterygium which has become attached to the cornea is a certain 
limitation of mobility of the eyeball in the opposite direction, owing 
to the restraining fibres of the growth. The pterygium is covered by 
the conjunctival and corneal epithelium, which is markedly hyper- 
trophied, and on reaching the cornea the growth extends beneath the 716 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
epithelium into the parenchyma of the cornea. Hence it is wise to 
remove a pterygium before it encroaches far upon the cornea, as it 
always leaves an opacity beneath it, which interferes with vision. 
Fig. 429. 
Fig. 430. 
Pterygium (Guthrie). 
Passage of a probe beneath a pterygium 
(Fuchs). 
Etiology.—A pterygium grows from the degenerative process exist- 
ing in a pinguicula, makes its way into and on the cornea, and draws the 
conjunctiva after it. This degeneration can generally be seen at the 
apex as a narrow gray, hazy zone which forms its anterior border and 
which is sharply defined from the clear cornea. This accounts for the 
pterygium being met with in a line with the palpebral fissure, where the 
conjunctiva is more exposed to external injuries, influences of tempera- 
ture or weather or occupation, such as wind, dust, foul or irritating 
atmosphere, etc. Microscopical examination of the apex of a growing 
pterygium shows a corrugation, and in places destruction of Bowman’s 
membrane and a cell-infiltration of the cornea beneath it. Small 
cavities are sometimes found here lined with endothelium, in which 
cocci have been met with. Histologically, a pterygium is identical with 
the ocular conjunctiva, and consists mainly of fibrillar connective tissue 
covered by epithelium. Bowman’s membrane is destroyed and the 
superficial lamellae of the cornea are replaced by the tissue of the 
pterygium. This explains why the cornea does not regain its trans- 
parency after the removal of a pterygium. The growth may occur at 
any age, but is usually met with beyond middle life. 
Treatment.—Several operations have been recommended for its 
relief, of which only two need be mentioned—viz. excision and trans- 
plantation. 
Excision is to be preferred in all cases in which the pterygium is narrow and 
not very thick, and the operation may be done under local cocaine anaesthesia. 
The eyelids must be beld open by a spring speculum, and tlie cul-de-sac and cornea 
thoroughly irrigated by a solution of bichloride of mercury (1:5000). The apex 
of the growth is seized with toothed forceps and carefully dissected off from the 
cornea with a small scalpel or a Beer’s cataract-knife. This dissection is to be 
carried some little distance beyond the corneal margin, keeping the knife closely 
in contact with the cornea and sclera. The knife is then laid aside and two con- 
verging incisions are to be made with blunt-pointed scissors, one from the lower 
border of the pterygium and one from the upper border, which should meet at a 
point a varying distance from the corneal margin according to the size of the HERPETIC AFEECTIONS. 
717 
pterygium. This removes the growth and leaves an irregular, rhomboid-shaped 
space on the eyeball. The whole surface of the wound should then be cleansed 
and the corneal wound scraped. The adjacent ocular conjunctiva above and 
below the wound should be loosed from the underlying sclera, and then the lips of 
the conjunctival wound should be closed with two or three fine sutures. Wet 
dressings and a bandage are then applied for twenty-four hours. This operation 
is applicable in almost all cases, and should be done early before the growth has 
encroached much on the cornea. 
Transplantation of a pterygium is an operation but rarely needed, and should 
only be done when the growth is very broad and thick. The operation to be 
recommended is Knapp’s modification of Desmarres’ method. The corneal apex 
of the pterygium is to be dissected off in the way already described, and then two 
curved incisions are made, running from the upper and lower borders of the base 
of the pterygium toward the corresponding retrotarsal fold. The corneal part of 
the growth is then excised, and the remaining portion is divided by a horizontal 
incision. A small square flap of conjunctiva is then dissected off from the sub- 
jacent tissue above and below the wound, so as to cover the latter. The contrac- 
tion thus produced causes the curved incisions to gape sufficiently to receive the 
horizontal halves of the pterygium, which are to be fastened in these incisions by 
sutures. The conjunctival flaps must then also be united by sutures. Simple cold 
dressings and a bandage are then to be applied for twenty-four hours. 
Phlyctenular conjunctivitis appears in the ocular conjunctiva in 
the form of one or several eruptive vesicles along the corneal limbus or 
in the free conjunctiva. The eruption may be dull red with smooth 
elevation, but the epithelium is soon cast off and an ulcer appears. Each 
point of eruption has usually its own area of congestion. These vesicles 
may be accompanied by a general catarrhal conjunctivitis, and this deter- 
mines the amount of the secretion. 
The symptoms are slight smarting, lachrymation, mucous secretion, 
and spasmodic closure of the lids. The duration is from three days to 
two or more weeks. The disease is usually associated with bad hygienic 
surroundings, a scrofulous taint, and generally feeble health. It is much 
more common among children than adults. It is best treated with warm 
applications, a boric-acid lotion, a very weak ointment of the yellow 
precipitate of mercury (gr. \ : sj), or finely powdered calomel dashed into 
the eye. 
Herpes zoster ophthalmicus is a neuropathic affection having its 
cause in a degeneration of the ganglion of Gasser or of the branches of 
the trigeminus, or both. Any of the branches of the trifacial nerve 
may be affected, and the vesicular eruption appears in the course of dis- 
tribution of the diseased nerve-filaments. These vesicles appear on the 
conjunctiva and cornea, as well as on the eyelids, surrounded by a zone 
of injection, and the inflammatory action may be so severe as to cause 
not only ulceration of the cornea, but iritis. It is confined to one side, 
and the symptoms consist, in addition to the appearance of the vesicles, 
of intense pain in the course of the affected nerve-twigs; redness, swell- 
ing, and sensitiveness of the skin of the cheek, lids, and forehead, 
resembling erysipelas; slight conjunctival discharge; and great photo- 
phobia and lachrymation. The pain sometimes ceases when the vesicles 
have ruptured. The disease may occur at any age, and is apt to be 
associated with a low condition of the system. 
The treatment consists in making continuous hot fomentations to 
the parts, the instillation frequently of a few drops of a solution of 
atropiae sulphat. gr. ij, and cocaine hydrochlor. gr. x in the ounce of water, 
and the administration of full doses of morphia and quinine three times 718 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
a day. The ulcers sometimes leave permanent scars, and the disease has 
been known to produce destructive irido-choroiditis and atrophy of the 
optic nerve. 
Pemphigus of the conjunctiva is a very rare disease, and may exist 
independently of the disease in other parts of the body. The affection 
is characterized by the rapid development of several large vesicles or 
bullae in the ocular or palpebral conjunctiva, which contain a turbid 
serum, accompanied by a sharp attack ot general conjunctivitis, lachry- 
mation, and photophobia. When these bullae burst there is left a raw, 
excoriated surface, which secretes a thick muco-purulent discharge. 
These raw surfaces frequently give rise to symblepharon. 
Treatment is of little or no avail, for in the cases in which sym- 
blepharon does not result the tendency of the disease is to complete 
destruction of the mucous membrane and-the formation of the condition 
known as xerophthalmia: cold applications, weak boric-acid solutions, 
and the free use of fatty substances make the patient more com- 
fortable. 
Xerophthalmia, or xerosis conjunctivse, is an extreme degeneration 
and atrophy of the conjunctiva, and is caused by trachoma or pemphigus 
in the advanced stages, and is the condition existing in complete sym- 
blepharon. The mucous membrane is absolutely dry, very much thick- 
ened, of a dusky-red color, and its surface is rough and scaly. The cul- 
de-sac is wanting, the cornea is opaque and roughened, and the cilia are 
usually absent from atrophy of the hair-bulb. 
All treatment is useless, but the patients may have their condition 
palliated by the employment of emollients. 
Morbid Growths in the Conjunctiva.—Syphilitic lesions of the 
conjunctiva include chancre, mucous patches, and circumscribed or dif- 
fuse gummata. Chancre and mucous patches occur most frequently in 
the palpebral conjunctiva, and usually involve the edge of the lid, 
though the latter have been met with in the ocular conjunctiva. The 
gummata are found in both the ocular and the palpebral conjunctiva, 
and if diffuse are apt to involve the whole thickness of the lid. The 
preauricular lymphatic nodes are generally involved. The chancre 
presents the usual appearance of a primary sore, but owing to its loca- 
tion has often been mistaken for an epithelioma. With regard to the 
mucous patch and gumma we are assisted in our diagnosis bv other con- 
stitutional symptoms and by the history of the case. These lesions 
require no surgical interference, and must be treated constitutionally and 
locally in the usual way. 
Tubercular disease of the conjunctiva appears as an open grayish ulcer from 
which nodules arise either within its area or on its margin, and is generally found 
in the palpebral conjunctiva. The lesion consists mainly of giant cells in which 
are found the bacilli. 
Lupus presents very much the same appearance, except that it involves the 
skin at the edge of the lid as well. In both lupus and tubercular disease the 
lymphatic nodes in the vicinity are apt to be swollen. If the eyeball be not in- 
volved, thorough excision of both these morbid growths is promptly indicated. 
If the eyeball be invaded, enucleation and exenteration of the orbit is the only 
chance for the patient. 
Polypi and papillomata resemble similar growths on other mucous 
membranes. They must be carefully excised and their bases cauterized. TUMORS OF THE CONJUNCTIVA. 
719 
Primary angeioma of the conjunctiva is a rare disease, the growth usually 
originating in the lid. It is a congenital affection, and is to be treated in the same 
way as angeioma of the lid or orbit. 
The cystic tumors occasionally met with in the conjunctiva generally originate 
in dilated lymphatics or in pre-existing glands. Large cysts beneath the conjunc- 
tiva are formed by the cysticercus cellulosae. Their contents are usually a pellucid 
fluid. Where possible they should be carefully dissected out with the cyst-wall intact. 
Lipomata occur beneath the conjunctiva of the fornix or of the eyeball, and 
are generally situated near the outer canthus. They 
are congenital, yellow in color, and soft in consist- 
ency, and, if desired by the patient, are very easily 
removed. 
Amyloid disease of the conjunctiva is not a true 
tumor, but a diffuse infiltration and degeneration of 
the conjunctiva and subconjunctival tissue. It grows 
very slowly, and rarely involves the ocular conjunc- 
tiva. The prognosis is good, and the only treat- 
ment is complete extirpation. A small section cut 
from such a growth readily shows the distinguishing 
reaction to iodine aud sulphuric acid. 
Dermoid tumors are flat or rounded growths of 
solid consistence on the eyeball, situated partly in 
the ocular conjunctiva and partly in the cornea, and 
they are very intimately connected with the cornea. 
They are white or yellowish-white in color, covered by epidermis and occasionally 
by long hairs, and resemble closely in structure the true skin. They are always 
congenital, and are sometimes associated with coloboma of the eyelid. They arise 
either from a foetal invagination of the external germ-layer or a circumscribed 
adhesion between the amnion and the surface of the eyeball. They are easily 
removed by excision with a sharp 
Beer’s knife, carefully dissecting the 
growth from the cornea and sclera, 
and covering the wound by drawing 
the conjunctiva over it (Figs. 431-433). 
Fig. 431. 
Dermoid of cornea (Bull). 
Fig. 433. 
Fig. 432. 
Epithelioma originating in the conjunctiva is almost always found 
at the limbus. It forms a non-pigmented, flat, sessile tumor with a broad 
base, usually situated on the nasal or temporal side of the cornea. It 
remains for a long time confined to the superficial layers of the con- 
junctiva and cornea, and shows a marked tendency to ulceration. If 
such a tumor be seen early and be found to be strictly superficial, it is 
possible to remove it entire, and then the wound should be thoroughly 
cauterized. If, however, it have grown extensively superficially or have 
involved the deeper tissues, the only tiling to advise is an immediate 
enucleation and exenteration of the entire orbit. 
Dermoid tumors of conjunctiva and cornea (Bull) 720 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
Primary sarcoma of the conjunctiva also almost invariably begins 
in the limbus, and is here generally pigmented, because of the presence 
of pigment in this region normally. A sarcoma grows more in height 
than in breadth, and has a relatively narrow base, so that it appears as a 
dark, prominent, mushroom-like growth which may cover a large part 
of the cornea. A sarcoma grows more rapidly than an epithelioma, 
sometimes attains an enormous size, and, except in the very beginning, 
always demands a most radical operation. In these cases of rapid 
growth the eyeball must be removed, even if the visual power be still 
fairly good. Sarcoma is more apt to involve the eyeball than epithe- 
lioma, and is much more likely to return in the orbital tissue. 
Fibromata and osteomata are of extreme rarity in the conjunctiva. 
They are annoying from their size and weight, and should early be 
removed. They show no tendency to return. 
Symblepharon. 
Symblepharon is a cicatricial adhesion between the conjunctiva of the 
eyelids and the conjunctiva of the eyeball, and occasionally the cornea. 
This may be partial or complete—that is, it may extend from the ciliary 
margin of the lid to the cul-de-sac, and from one end of the lid to the 
other—or the adhesion may consist of one or more bands, more or less 
tendinous in appearance, running from the lid to the eyeball. These 
sometimes admit of a probe being passed beneath them. If the adhe- 
sions be complete between one or both lids and the eyeball, and extend 
to the cul-de-sac, the case cannot be cured by operative interference, and 
should either be left untouched or the eyeball should be removed and 
the orbital cavity closed by stitching the lids together. 
Etiology.—Any circumstance which can give rise to the formation of 
raw surfaces on the palpebral and ocular conjunctive will cause sym- 
blepharon. Hence the most frequent causes are burns by the action of 
heat or molten metal or caustic substances. A symblepharon may also 
be caused by operations, by ulcers of all kinds, and even by diphtheritic 
conjunctivitis. 
The contraction of the conjunctiva which occurs as a result of its gradual 
shrinking, which is so often seen after granular lids or trachoma, is not a true 
symblepharon, because there is no adhesion between two raw surfaces, but is rather 
a narrowing of the cul-de-sac. In advanced cases of this nature the fornix ceases 
to exist, and the conjunctiva of the lids extends directly to the eyeball. Such cases 
do not admit of operative interference. 
Treatment.—If the adhesion between the lid and the eyeball con- 
sist of a single tendinous band, reaching from the lid to the globe and 
usually involving the corneal margin, Arlt’s operation generally gives 
satisfactory results. The tip of the attachment to the eyeball is grasped 
with toothed forceps, and the band is dissected away from the globe as 
far as the cul-de-sac, leaving a raw surface on the ball. A suture armed 
with two needles is then passed through the free end of the frsenum, and 
the needles are then pushed through the cul-de-sac to the surface of the 
skin, the ligature is drawn tight, and the two ends are tied over a bit of 
plaster or rubber tubing. This brings the epithelial surface of the 
fraenum next the raw surface of the eyeball. This raw surface is next 
covered over by dissecting up and bringing down flaps of conjunctiva SYMBLEPHARON. 
721 
from either side. A glass shell may then be inserted and worn over the 
eye, so as to aid in preventing undue contraction. 
If the symblepharon be more extensive, this operation will not suffice, and 
resort must be had to one of the many plastic operations devised by Teale, Knapp, 
and others. In every case the adhesive bands are to be dissected free from the 
eyeball as far as the fornix, and the raw surface 
on the eyeball is then to be covered, leaving 
that on the lid to take care of itself. 
Teale’s operation consists as follows (Figs. 
434, 435, and 436) : An incision is to be made 
through the adherent lid in a line correspond- 
ing to the margin of the concealed cornea, and 
the lid is then to be dissected from the eye as 
far as the fornix (Fig. 434). Two flaps of con- 
junctiva are then formed—one from the sur- 
face of the globe near the inner extremity of 
the raw surface, the other from the surface of 
the globe near the outer extremity, the apex of each passing toward the upper sur- 
face of the eyeball (B and C, Fig. 435). These flaps are carefully dissected from 
the globe until they are free enough to stretch across the chasm without great ten- 
sion, care being taken to leave a sufficient thickness of tissue near their bases. The 
two flaps thus made are then adjusted in their new situation (Fig. 436). The inner 
flap, B, is stretched across the raw surface of the eyelid, while the outer flap, C, is 
Fig. 434. 
Fig. 435. 
Fig. 436. 
made to cover the raw surface of the eyeball, and both are stitched to healthy con- 
junctiva at their apices; and thus the two flaps are dovetailed into the wound. 
The margins of the gaps whence the flaps were taken are sutured. The apex of 
tissue left attached to the cornea soon atrophies. 
Teale’s operation for symblepharon 
The transplantation without pedicle of pieces of healthy conjunctiva 
from the human eye or from the rabbit’s eye, or of the buccal mucous 
membrane, to cover the raw surface on the eyeball made by the detach- 
ment of the adhesive bands, is another method employed for the cure of 
symblepharon which sometimes gives satisfactory results in bad cases. 
Wolfe of Glasgow was the first to recommend this method. 
Ankyloblepharon is a more or less extensive cicatricial adhesion of 
the edges of the eyelids to each other. It may be either partial or total, 
and often coexists with symblepharon, the same injury having given rise 
to both these conditions. The effect of ankyloblepharon is to diminish 
the length of the palpebral fissure and hinder the movements of the lids. 
Etiology.—The most frequent causes of ankyloblepharon are chem- 
ical and mechanical injuries, such as burns or scalds from hot fluids or 
molten metals, strong acids, etc. Blepharitis, accompanied by ulcerations 
at the edges of the lids, may produce it if the ulcers be opposite each 
other on the lids and if the eyes be kept closed for any length of time 
by a bandage. 722 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
Treatment.—Before operating for the relief of ankyloblepharon we 
must ascertain whether symblepharon also exists, and, if so, how exten- 
sive it is; for if the lid be adherent to the cornea, very little benefit can 
be expected from an operation. If the adhesion extend as far as either 
eanthus, the edges of the lids must not only be separated, but the eanthus 
must be covered by a lining of conjunctiva, or else , the adhesion will 
form there again. 
If a small opening exist at or near the canthus, and the adhesion be partial 
and confined to either angle, a probe should be passed through the opening under 
the lid to determine the presence of 
bands of adhesion to the eyeball (Fig. 
437). A grooved director may then be 
passed through the hole and the adhe- 
sion between the lids carefully divided. 
If there be no symblepharon, a small 
strip of conjunctiva from the lid or cul- 
de-sac may then be transplanted to the 
edge of one of the lids and stitched in 
position, so as to cover it with an epithe- 
lial surface and prevent readhesion. 
When symblepharon is present with 
the ankyloblepharon, the extent of the 
former will enable us to decide whether an operation will be of any practical value. 
If the ankyloblepharon be total, no operation is justifiable, as extensive adhesions 
between lids and eyeball are always present and the cornea is seriously involved. 
Fig. 437. 
Relief of ankyloblepharon (Lawson). 
Diseases of the Lachrymal Apparatus. 
The only malformation, so called, of the lachrymal gland of which we have any 
knowledge is rather a displacement or dislocation than a true malformation, and 
seems to be due to an undeveloped or relaxed condition of its enveloping capsule. 
In this condition the gland presents beneath the ocular conjunctiva over the 
insertion of the external rectus muscle, causing a visible protuberance and some 
interference with the mobility outward of the eyeball. If it produce great annoy- 
ance, the displaced gland may be removed through an incision in the conjunctiva. 
Dacryo-adenitis, or inflammation of the lachrymal gland, may he 
acute or chronic in character. If the former, it rapidly develops into 
an abscess. 
The symptoms consist in the appearance of a firm, nodulated, im- 
movable swelling at the upper and outer angle of the orbit; redness and 
pufliness of the upper lid, causing the lid to droop; injection and chemosis 
of the conjunctiva; tenderness on pressure of the gland and neighboring 
orbital margin ; dull pain ; and possibly displacement of the eyeball 
downward and inward. The inflammation may develop rapidly into an 
abscess with all the signs of suppuration ; the abscess points and dis- 
charges usually through the skin of the lid near the external canthus, 
though it may do so through the conjunctival cul-de-sac. 
Etiology.—Dacryo-adenitis may be due to cold, to traumatism, to 
purulent conjunctivitis, to orbital cellulitis, or to periostitis of the orbit. 
Treatment.—This consists in the use of hot fomentations and in 
free incisions into the swollen gland through the skin of the lid beneath 
the orbital margin or through the conjunctival cul-de-sac. If an abscess 
of the gland have perforated spontaneously through the lid, it may 
leave a permanent fistula, This should be treated by making and main- 
taining a free opening into the gland through the conjunctival fornix, THE LACHRYMAL CANALICULI, SAC, AND DUCT. 
723 
and then slitting up the fistulous traet on a grooved director and treating 
it as any other fistula. 
Cystoid Disease of the Gland.—Cysts of the lachrymal gland are 
of rare occurrence. 
The symptom of such a cyst is the appearance of a small, elastic 
swelling at the upper and outer angle of the upper lid. When the lid is 
everted the cyst appears as an elastic, fluctuating swelling, which increases 
rapidly in size if the patient weep or if the conjunctiva be irritated. 
It is due to the stoppage of one or more of the excretory ducts of the 
gland. 
The treatment should consist in making an artificial opening on 
the inside of the conjunctiva by removing a portion of the cyst-wall, so 
that the secretion may have free exit. 
Tumors of the Lachrymal Gland.—Tumors or new growths origin- 
ating in the lachrymal gland are of extremely rare occurrence. Almost 
all the cases hitherto reported have been instances of extension of the 
new growth from the connective tissue of the orbit or the periosteum to 
the gland. Cases have been reported of all the various pathological new 
growths occurring in the gland, the most frequent being sarcoma. 
The symptoms are the same for all these neoplasms—pain and swell- 
ing in the orbit and upper lid and displacement and protrusion of the 
eyeball. 
Treatment consists in extirpation of the lachrymal gland, which 
should be done as soon as possible after the nature of the disease has 
been recognized. 
If the growth appear to have originated in the gland, the operation is done as 
follows: The lids are put on the stretch at the external cantlius, and the com- 
missure is divided by a horizontal incision from half an inch to an inch in length. 
The skin, muscle, and tarso-orbital fascia at the outer third of the lid are then to 
be divided by a curved incision just beneath the superior orbital margin, the outer 
end of which should join the outer end of the horizontal incision. This makes a 
triangular flap which is displaced inward, and an entrance into the orbit is thus 
made, and the gland is easily reached with a hook, pulled forward, carefully sep- 
arated from its attachments, and removed. The wound should then be cleansed, 
and after all bleeding has ceased it should be closed by deep sutures, which should 
include the divided tarso-orbital fascia and the edge of the periosteum, so as to 
avoid the subsequent occurrence of ptosis. 
The Lachrymal Canaliculi, Sac, and Duct. 
Malformations.—Among the malformations or congenital anomalies 
the most frequent are duplications of the puncta and canaliculi, and also 
their entire absence. In the case of the latter any attempt to create a 
natural passage for the tears into the lachrymal sac generally ends in 
failure. 
The terms epiphora and stillicidium lachrymarum mean an overflow of tears 
upon the external surface of the lids and cheek from inability to find exit through 
the punctum and canaliculus to the lachrymal sac. This may be due to a congen- 
ital absence of the puncta or to their displacement by inversion or eversion of the 
lids from disease, or to traumatism, or to some obstruction in the nasal duct. In 
many cases this may be relieved or entirely cured by slitting up one or both canal- 
iculi from the puncta to their opening in the lachrymal sac, which is done in the 
following way : The operator should stand behind the patient, using his right hand 
for the right eye of the patient, and the left hand for the left eye. A probe-pointed 
Weber’s knife' is then introduced vertically into the lower punctum, and immedi- 724 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
ately turned into the horizontal plane, with the edge directed upward and slightly 
backward toward the eye, and the knife is immediately pushed toward the median 
line until the point strikes the lachrymal bone. A probe may then be passed into 
the sac and down into the duct, and the presence of any obstruction at once de- 
tected. The incised canaliculus should be kept from closing by the daily passage 
of the probe until the cut edges have healed. 
Dacryo-cystitis, or inflammation of the lachrymal sac, is of two 
kinds—catarrhal and 'purulent. The former is called mucocele, and 
always exists in connection with catarrh of the nose or conjunctiva, or 
both. 
The symptoms begin with epiphora, followed by slight and occasional 
swelling in the region of the lachrymal sac, and slight oozing of a few 
drops of a turbid, viscid mucus, which is increased in amount by pressure 
over the sac. This catarrhal condition may exist for a long time with- 
out change, but sooner or later it develops into the purulent form, with all 
the symptoms intensified, and the discharge is purulent. When pressure 
on the sac succeeds in emptying it downward through the nose, there is no 
stricture ; but if the sac can only be emptied through the puncta, there is 
a stricture somewhere, and usually at the juncture of sac and duct. The 
purulent form may at any moment assume the type of acute phlegmonous 
inflammation and abscess, with severe pain, the appearance of a hard, 
tense tumor over the sac, which is acutely sensitive, great swelling of 
the lids and neighboring parts, with a red, glistening, tense condition of 
the skin, and in severe cases complete closure of the lids. This condi- 
tion of phlegmonous inflammation, if left to itself, ends in ulcerating 
through the skin just below the level of the internal canthal ligament, 
and in the formation of a lachrymal fistula. 
Fig. 438. 
Abscess of lachrymal sac (Dalrymple). 
Etiology.—Dacryo-cystitis is almost always caused by extension of 
disease from the nose, either a nasopharyngeal catarrh or a periostitis, 
with actual bone disease of the duct. More rarely it has been known THE LACHRYMAL CANALICULI, SAC, AND DUCT. 
725 
to arise from purulent conjunctivitis and from caries of the lachrymal 
bone and ethmoid labyrinth. 
Treatment.—Our efforts should be directed toward preventing the 
onset of the phlegmonous attack. When the condition is that of muco- 
cele, one or both canaliculi should be incised, the sac emptied of its con- 
tents and washed out, and a probe passed into the duct. If a stricture 
be present, it is found usually at the junction of the sac and duct, and 
must be divided. 
The surgeon stands behind the patient and introduces a long probe-pointed 
Weber’s knife, with malleable shaft, into the canaliculus, and pushes it along until 
its point is in contact with the lachrymal bone. Then, keeping the point pressed 
against the lachrymal bone, the handle is rapidly brought up to the perpendicular 
with the edge forward, and then driven straight down through sac, stricture, and 
duct to the floor of the nose. If the stricture be found to be tense and broad, this 
manoeuvre must be repeated several times with the edge of the knife turned in dif- 
ferent directions, so as to divide the stricture several times. Then a Theobald 
inflexible steel probe of large size (No. 12 or 14) should be passed, exactly as was 
the knife, to the bottom of the duct. If these directions be carefully followed, no 
false passage will be made (Fig. 439). The probe should be passed daily until the 
lips of the wound have become glazed over, and the sac and duct should be irri- 
gated with an antiseptic astringent solution until all secretion has ceased. 
If the case be one of phlegmonous dacryo-cystitis, our first efforts should be 
directed toward allaying the acute inflammation, which is done by the continuous 
Fig. 439. 
Method of inserting Bowman’s probe (Norris and Oliver). 
application of hot bichloride fomentations (1: 5000), and the pain should be relieved 
by anodynes. If we succeed in doing this before the occurrence of a hstula, these 
cases do well. As soon as the acute swelling and tenderness have subsided and the 726 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
puncta can be seen, one or both canaliculi are to be incised, and the stricture is to 
be thoroughly divided as before directed. Then a thorough irrigation of the sac 
and duct through to the nose with hot bichloride solution should be done, and this 
should be followed by the passage of the steel probe as before. The irrigation and 
probing should be done daily for ten days or two weeks, and then at longer inter- 
vals, and the hot fomentations should be continued as long as any acute inflamma- 
tory symptoms remain. 
Diseases of the Cornea. 
The diseases of the cornea which require surgical interference would scarcely 
come under the care of a general surgeon. The ordinary forms of keratitis, ulcer, 
and abscess of the cornea do not come within the scope of this work, but a few 
brief remarks in regard to those affections of the cornea which demand the aid of 
the knife may not be out of place here. 
Conical Cornea, or Keratoconus.—This is an alteration in the 
natural curvature of the cornea, so that it becomes conspicuously conical, 
without any alteration in its transparency. It is not an inflammatory 
process, but an atrophy of the corneal substance. The conicity may be 
more or less globular, and the apex of the cone may be central or more 
or less peripheral. The disease is generally met with in young people, 
is of slow progress, and sometimes is spontaneously arrested. There is 
sometimes pain ; there may be marked symp- 
toms of asthenopia; and the vision for all 
distances is much impaired and cannot be 
improved by glasses, because of the discom- 
fort occasioned by them (Fig. 440). Various 
surgical procedures have been essayed either 
to improve the vision or to correct the de- 
formity. Iridectomy and iridodesis have been 
recommended, the object being to displace the 
pupil toward the periphery, and then supple- 
ment it by tattooing the apex of the cone. 
Bowman advised trephining the apex of the cone and removing a small disk 
of corneal tissue, leaving the opening to close by granulation, but this requires a 
subsequent iridectomy. Another method is to cauterize the apex with the actual 
or galvano-cautery, and repeat the burning until a suitable effect is gained. Per- 
foration of the cornea and prolapse of the iris are apt to occur, and iridectomy will 
then become necessary. A simpler method is the excision of a small piece of 
cornea and the closing of the wound by very fine sutures. 
Fig. 440. 
Conical cornea (Bull). 
Fig. 441. 
Fig. 442. 
Total staphyloma of cornea (Bull). 
Total staphyloma of cornea (Sichel). 
Staphyloma of the Cornea.—This deformity is usually the result 
of extensive ulceration and perforation of the cornea with prolapse of IRITIS AND IRIDO-CYCLITIS. 
727 
the iris, and appears as an irregular conical or rounded protuberance 
which is more or less opaque. It may be either very vascular or 
entirely devoid of visible blood-vessels (Tigs. 441, 442). The intra- 
ocular tension is usually increased. 
The protrusion may be excised, and the large opening closed by introducing 
sutures through the ocular conjunctiva and drawing the latter over the hole in the 
eyeball, but the safer procedure is to enucleate the eyeball, especially if the patient 
be an adult, as sympathetic ophthalmia has been known not infrequently to follow' 
excision of a corneal staphyloma. 
Morbid Growths of the Cornea.—It is still doubtful whether 
tumors originate primarily in the cornea. We meet with fibroma, sar- 
coma, epithelioma, papilloma, and dermoid tumors. The latter are 
congenital, involve the limbus, and start from the conjunctiva, as does 
the epithelioma. Leprous nodules and tuberculous deposits have been 
reported as occurring in the cornea. The papillomata and the dermoid 
tumors may be excised and do not return, but in all cases of sarcoma 
and epithelioma the eyeball should be enucleated at once. 
The anatomical connection between the iris and the ciliary body is 
so intimate that disease of the one is very apt to involve disease of the 
other. This is particularly true when iritis or cyclitis is due to some 
constitutional cause like syphilis or rheumatism, and also in the case of 
tumors. One of the most frequent mistakes in diagnosis made by the 
student and general practitioner is in confounding iritis with some other 
ocular disease, usually conjunctivitis; but if due attention be given to 
the symptoms of inflammation of the iris as here enumerated, such a 
mistake is not likely to occur. 
Iritis is an inflammation of the iris, with infiltration of its tissue and 
more or less marked exudation upon the anterior and posterior surfaces 
of the iris, mainly the latter, and into the anterior chamber. 
The SYMPTOMS which are usually present in all forms of iritis are as 
follows: Circumcorneal injection ; haziness or turbidity of the aqueous 
humor; swelling, discoloration, and sluggishness or immobility of the 
iris ; irregularity in shape or size of the pupil; impaired vision ; photo- 
phobia ; lachrymation ; and pain. 
The distinguishing point between iritis and conjunctivitis is the cir- 
cumcorneal or ciliary injection. There are two very common varieties 
of ocular injection, which must be thoroughly differentiated so as to be 
recognized at a glance. The most frequent of these is the conjunctival 
injection, consisting of long, superficial, tortuous vessels, running from 
the fornix toward the cornea, which are indirectly branches of the 
external carotid. They are always present in conjunctivitis, and are 
darker in color than the vessels met with in the circumcorneal injection. 
The second injection is the ciliary or circumcorneal, consisting of short, 
deep, straight vessels, rarely more than one-sixteenth of an inch long, 
pink or scarlet in color, which form a more or less complete zone imme- 
diately around the corneal margin. They are branches indirectly of the 
internal carotid through the medium of the ciliary and ophthalmic 
arteries, and are present in keratitis, iritis, and cyclitis, but are never 
present in conjunctivitis. 
Iritis and Irido-cyclitis. 728 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
The following points of differential diagnosis are very necessary to remember 
to enable us to distinguish between conjunctivitis, keratitis, and iritis. In con- 
junctivitis there is always injection of the inner surface of the eyelids, as well as 
of the ocular conjunctiva, and in the latter the injected vessels are superficial, 
long, and tortuous, and movable under the finger. There is usually some secretion 
of muco-pus and more or less swelling of the lids. 
If the cornea be involved, besides the injection of the short, deep, straight ves- 
sels around the corneal margin there is either infiltration of the transparent cornea 
or loss of substance as in an ulcer, or both. There may also be loss of brilliancy 
of the corneal surface and the presence of a conjunctival injection. 
If the iris be involved, besides the circumcorneal injection the other symptoms 
as previously given are present. In rare cases conjunctivitis and iritis coexist, 
and then we meet with the double injection. 
Plastic iritis is the most frequent variety of iritis, and is always 
marked by the presence of the above symptoms. Serous iritis is only 
one form of the plastic variety, and its presence is usually indicated by 
the appearance of punctate, brownish deposits on the posterior surface 
of the cornea. The exudation in plastic iritis is mainly from the poste- 
rior surface of the iris, and this fibrinous exudation glues the iris to the 
capsule of the lens and causes the adhesions known as “posterior 
synechiae,” which account for the irregularity in the shape of the pupil 
and the more or less marked immobility of the iris. 
If the plastic iritis be of the rheumatic or gouty variety, in addition to the 
usual symptoms a gelatinous or spongy deposit, highly fibrinous in character, is 
usually found in the anterior chamber, which in severe cases is apt to block the 
pupil and may even fill the anterior chamber. In this type of the disease the 
inflammation is not confined to the iris, but also involves the ciliary body and 
choroid. 
Purulent iritis is a rare disease, and, when not due to traumatism, is 
usually of metastatic origin or extends to the iris from the inflamed 
choroid. When the purulent process is confined to the iris, it is almost 
always of traumatic origin from some perforating wound of cornea and 
iris. In addition to the general symptoms of iritis, we also find small 
abscesses in the iris tissue, and occasionally hypopyon or pus at the 
bottom of the anterior chamber (Fig. 443). 
Gummatous iritis, or gumma of the iris, is by no means a rare affec- 
tion, and is met with only in syphilitic patients. The term “ syphilitic 
iritis” should be confined to this form 
of the disease, characterized by the pres- 
ence of a gumma in the tissue of the iris, 
either at the sphincter margin or at the 
periphery, and presenting as a distinct 
yellowish elevation, which is usually vas- 
cularized from base to summit. In 
syphilitic patients the iritis present is 
generally of the plastic type, and differs 
in no respect from any other case of 
plastic iritis; but a gumma of the iris 
gives a distinctive character to the case, 
and hence the name “syphilitic iritis” 
should be confined to this type of the disease. 
Tuberculous iritis comes more properly under the head of Tumors of 
the Iris, and will be there considered. 
Fig. 443. 
Iritis with hypopyon and chemosis of 
bulbar conjunctiva (Demours). OLA UCOMA. 
729 
Etiology.—Iritis may be caused by long-continued cold, and even 
by long-continued exposure to the heat and glare of the sun, as in the 
tropics, and is then a purely local, idiopathic disorder. The other local 
causes are traumatism and sympathetic inflammation. By far the most 
common cause is some general constitutional disease, and the most fre- 
quent of these is syphilis. Then follow, in the order of frequency, rheu- 
matism, gout, acute infectious diseases, tuberculosis, and diabetes. In 
all of these cases the iritis is of the plastic type, except in tuberculosis 
and in true syphilitic iritis with the development of a gumma. 
Prognosis.—The prognosis is generally very good, except in bad 
cases of rheumatic iritis and in tuberculous iritis. In the latter form 
the case ends in more or less marked destruction of the eye. 
Treatment.—This is divided into local and constitutional. Hot 
fomentations or dry heat should be employed to allay the inflammatory 
process and to promote absorption of the plastic exudation. Atropine 
should be instilled into the eye to dilate the iris and break up the pos- 
terior synechise, and, secondarily, to allay pain. The strength of the 
solution should vary from one grain to four grains to the ounce, or even 
stronger, according to the severity of the attack, and the latter should 
also regulate the frequency of the instillations. If there be severe pain, 
this may often be allayed by applying cups or leeches to the temple. 
The eye should be protected from the light by dark glasses or a shade, 
but never by a bandage, and the room in which the patient remains 
should be moderately darkened. 
The constitutional treatment should vary with the cause of the disease. If it be 
syphilis, the treatment by mercurials and potassium iodide should be pushed rap- 
idly to toleration, in order to forestall dense adhesions or the development of gum- 
mata. If rheumatism or gout be the cause, the patient must be brought as rapidly 
as possible under the influence of sodium salicylate, salicylic acid, or salol, in order, 
if possible, to prevent the spread of the disease to the choroid; for if the latter 
become involved, the vision is usually permanently impaired. There is no special 
treatment indicated for iritis due to diabetes or tuberculosis or the acute infectious 
diseases. The local treatment is the same for all varieties of iritis. 
The surgical treatment for the results of iritis or irido-choroiditis comes within 
the domain of the ophthalmic surgeon only, and should properly be left to him. 
The operations to be advised consist of iridectomy or iridotomy. In some rare cases 
enucleation of the eye becomes necessary as a prophylactic against sympathetic 
ophthalmia. 
Glaucoma. 
Glaucoma is the term applied to a morbid condition or variety of 
conditions of the eyeball, characterized by increased intraocular tension 
or hardness of the globe. It may be either primary or secondary, 
inflammatory or non-inflammatory, acute, subacute, or chronic. 
Symptoms.—The following symptoms are common to the disease, 
though they are not all constantly present in each variety : (1) Increased 
intraocular tension ; (2) change in the size and shape of the pupil and in 
the appearance and mobility of the iris; (3) loss of transparency in the 
cornea; (4) change in the depth of the anterior chamber; (5) turbidity 
of the aqueous and vitreous humors; (6) engorgement and tortuosity of 
the conjunctival and episcleral vessels; (7) excavation or cupping of the 
optic disk of the “ overhung ” variety and the surrounding “ glaucom- 
atous ring;” (8) pulsation of the veins, and sometimes of the arteries, 730 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
on the optic disk; (9) pain; (10) anesthesia of the cornea; (11) dimi- 
nution of central vision; (12) loss of accommodation; (13) narrowing of 
the field of vision, generally of the concentric variety, and most marked 
on the nasal side; (14) iridescent vision, or seeing colored halos around 
artificial lights. 
These symptoms, or such of them as are present, are always most 
marked in the acute inflammatory type of the disease. 
Chronic or simple, non-inflammatory glaucoma is the most frequent 
type of the disease. 
Causes.—Glaucoma is rarely met with before middle life. The 
refraction of a glaucomatous eye is generally hypermetropic, and very 
frequently astigmatic. In eyes predisposed to this disease an attack 
may be excited by mental worry, overwork of the eyes without glasses 
or with improper glasses, heart disease, and any disturbance of the vas- 
cular system. Many theories have been advanced to explain the mechan- 
ism of an attack of glaucoma, no one of which is entirely satisfactory. 
Prognosis.—The disease tends naturally, if unchecked, to absolute 
blindness, and hence the prognosis is unfavorable, though it depends on 
the type of the disease and the stage of development. The prognosis is 
most favorable in acute inflammatory glaucoma, and least so in simple 
chronic glaucoma. 
Treatment.—No satisfactory result is ever gained except by ope- 
ration. 
Eserine sulphate, in a solution of one-quarter to one-half a grain strength, will 
sometimes relieve the symptoms or postpone temporarily the advance of the dis- 
ease, and may always be used if an operation be not possible. But the only method 
of treatment which offers any hope of success is an operation to relieve the increased 
intraocular tension, and this may be either an iridectomy or a sclerotomy accord- 
ing to the nature of the case. This disease must be relegated to the domain of the 
ophthalmic surgeon, who alone is best fitted to cope with its difficulties. 
Sympathetic Ophthalmia. 
Sympathetic ophthalmia is the term applied to those affections of 
the eye, and mainly of the internal structures, which result from injury 
to or disease of the fellow-eye. It presents itself under two distinct 
forms, one of which is called sympathetic irritation, and the other sym- 
pathetic inflammation ; and they are two essentially different conditions. 
Sympathetic irritation is a neurosis or functional disturbance charac- 
terized by photophobia, lachrymation, blepharospasm, impaired accom- 
modation, subnormal vision, supraorbital neuralgia, photopsic manifes- 
tations, sometimes narrowing of the visual field, and an inability to 
continue close work. Any or all of these symptoms may be present in 
the uninjured or sound eye. During the occurrence of these symptoms 
in the second stage the injured or diseased eye is usually injected about 
the ciliary region, and there are photophobia, tenderness on pressure, 
ciliary neuralgia, and sensitiveness to light. These symptoms in both eyes 
may subside, only to recur again and again. 
Sympathetic inflammation is an ophthalmitis, usually confined to the 
nveal tract—i. e. the iris, ciliary body, and choroid—though it may 
involve the nerve and retina, either alone or in connection with the 
uveitis. More rarely it involves the conjunctiva or cornea, or both. SYMPATHETIC OPHTHALMIA. 
731 
It is characterized by pain, photophobia, lachrymation, circumcorneal 
injection, exudation into the aqueous or vitreous humors, punctate 
deposits on the posterior surface of the cornea, iritis, exudation into the 
field of the pupil, cataract, increased tension, narrowing of the anterior 
chamber, extreme sensitiveness on pressure, and loss of sight. These 
symptoms may end in subnormal tension and atrophy of the whole eye- 
ball. Sometimes the first intraocular symptoms are those of neuro- 
retinitis before the uveal tract has become involved. These symptoms 
may be acute or chronic. 
Etiology and Pathogenesis.—According to the most recent in- 
vestigations, all the nerve-structures of the diseased or injured eye may 
assist in the transmission of the trouble to the fellow-eye. The causes 
maybe as follows: (1) Foreign bodies in the eye; (2) punctured, incised, 
or lacerated wounds of the ciliary region; (3) wounds or ulcers of the 
cornea, with incarceration or prolapse of the iris; (4) operations on the 
eyeball, such as discission, iridectomy, iridodesis, extraction of cataract, 
and anterior sclerotomy; (5) traumatic cataract and dislocation of the 
lens; (6) ossification of the choroid and ciliary body; (7) intraocular tu- 
mors; (8) incarceration of the ciliary nerves and stump of the optic nerve 
in cicatricial tissue, after enucleation ; (9) more rarely, pressure of an 
artificial eye upon the stump. 
The period of time between the receipt of the injury or the onset of the disease in the 
first eye, and the development of sympathetic trouble in the fellow-eye, varies within 
wide limits, from forty-eight hours to many years, but the disease usually develops 
within the first three months. The term “ sympathetic ” was first applied to this 
disease because it was originally thought that it was due to a reflex action through 
the ciliary nerves. Of recent years this theory has been abandoned by many for 
the theory “ by infection,” in which the course of the micro-organisms is through 
the medium of the sheaths of the optic nerves, the possibility of which has been 
demonstrated by Deutschmann. Hence the name “migratory ophthalmitis” has 
been proposed for this disease. 
Prognosis.—The prognosis of sympathetic ophthalmia is always 
unfavorable, especially if the uveal tract have been involved. If the 
sympathetic inflammation be of the nature of a simple serous iritis or a 
neuro-retinitis, without participation of the ciliary body or choroid, it may 
be possible to promise a partial recovery of vision. It is much more 
favorable if treatment be undertaken during the stage of sympathetic 
irritation. 
Treatment.—This varies according to the existing stage of the 
affection in the second eye. If the condition of the second eye be that 
of sympathetic irritation only, without any signs of sympathetic inflamma- 
tion, prompt enucleation of that injured or primarily diseased will, in the 
great majority of cases, prevent the occurrence of sympathetic ophthalmia 
in the second eye. If, however, sympathetic inflammation have already 
begun, enucleation should not be done if there be any vision in the first 
eye, for the operation will have no effect upon the diseased process in 
the second eye, and very often the resulting vision in the injured eye 
will be better than that in the eye secondarily affected. 
No operation, such as iridectomy or sclerotomy, on the sympathetically 
inflamed eye ever brings about any favorable result upon the course of 
the inflammatory process. The surgeon should wait until all inflam- 732 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
matory symptoms have subsided before attempting any surgical inter- 
ference. 
In sympathetic ophthalmitis the patient should be kept in a darkened room. 
Leeches should be applied to the temples as often as may be necessary, and atro- 
pine and cocaine in the same solution should be instilled frequently unless there 
be marked increase of the tension. Tonics and alteratives should be administered, 
and small doses of mercurials if the health of the patient admit. If the patient 
suffer from confinement, his eyes should be bandaged, and moderate exercise in 
the open air be prescribed daily. 
In place of enucleation it has been proposed to perform either optico- 
ciliary neurotomy or neurectomy. The first of these consists in dividing 
the optic and ciliary nerves behind the eye, leaving the globe in situ. 
The second consists in excising a portion of the optic and ciliary nerves 
behind the eye, also leaving the globe intact in the orbit. 
The first of these methods, the neurotomy, may be rejected, as sympathetic in- 
flammation has been known to extend to the fellow-eye after such a neurotomy, 
the divided ends of the nerves being left more or less closely in apposition. The 
second operation, neurectomy, has been known to serve its purpose, though some- 
times followed by profuse hemorrhage behind the eyeball. 
The following indications may be laid down for the enucleation of the 
first eye before the outbreak of sympathetic inflammation in the fellow- 
eye : 
(1) When the wound is in the ciliary region, and is so extensive as to 
greatly damage or entirely destroy the vision ; 
(2) When the wound is in the ciliary region, and is already accom- 
panied by iritis and cyclitis; 
(3) When the eye contains a foreign body, and all attempts at its 
removal have proved futile; 
(4) When the eye is shrunken and atrophied, and tender on pressure 
or continually irritated. 
The name cataract is applied to an opacity of the crystalline lens or 
its capsule and may be either partial or complete. Its causes may be 
either local or constitutional. It may be stationary or progressive ; ripe 
or unripe; soft, hard, or hypermature; simple or complicated ; traumatic, 
idiopathic, or congenital. • 
Cataract. 
The opacity may begin at the periphery or in the nucleus of the lens, or in 
both regions at once. Senile cataract generally begins at the periphery and ex- 
tends toward the centre, and until it encroaches on the field of the pupil is not 
recognizable except by the skilled ophthalmic surgeon. 
The one subjective symptom is a slow and 'progressive failure of vision. 
If, on examining the eyes of such a patient the pupil be found to be of a 
gray or whitish color, instead of black, and the opacity to be distinctly 
behind the plane of the iris, the trouble is either in the lens or in the 
anterior layers of the vitreous humor, and by dilating the iris with some 
mydriatic it can be determined exactly where the opacity is situated. 
Dense opacities in the vitreous humor are rarely so tar forward as to 
give a white reflex from the pupil. If, on the contrary, the gray or 
whitish opacity be in front of the plane of the iris, it must be either in PANOPHTHALMITIS. 
733 
the cornea or in the anterior chamber, and a closer inspection with oblique 
illumination will determine its location. 
Sometimes an intraocular tumor growing from the retina or choroid has by the 
unskilled been mistaken for a cataract. But usually these tumors show a network 
of blood-vessels running over them, which never exist in a cataract. 
A senile cataract usually occurs in both eyes, though it may be farther ad- 
vanced in one eye than in the other. Soft cataracts may be unilateral or bilateral, 
and, if not due to traumatism and not congenital, are symptomatic of some gen- 
eral systemic disorder, or due to some previous inflammatory process in the deeper 
parts of the eye. They occur not infrequently in diabetes, more rarely in disease 
of the liver or kidneys, and have sometimes been met with as a sequel of the 
continued fevers. In such cases they are the result of malnutrition of the lens. 
There are many varieties of cataract which are of interest solely to 
the ophthalmologist. The tendency of all cataracts is to increase slowly 
until the whole lens is involved, but to this rule there are exceptions. 
In myopic eyes lens opacities grow very slowly, and are often stationary 
for years. In rare cases the opacities of the lens have been known to 
diminish, and even to disappear, with corresponding improvement in 
the vision. 
The prognosis as to vision is unfavorable unless an operation be 
done. The prognosis as to vision after operation is favorable, the great 
majority of patients recovering useful, and many of them very acute, 
vision. 
Treatment.—In congenital cataracts and the soft cataracts of youth 
the best results are gained by keratonyxis or discission, which consists in 
the introduction of a needle through the cornea, lacerating the capsule 
and stirring up the lens-tissue, and then waiting for absorption to take 
place, trusting to the production of a more or less open pupillary space, 
through which the patient may see. In hard cataracts of all varieties in 
the adult the only operation which promises any satisfactory results is 
the extraction of the lens. 
The operation of extraction may be either simple or combined, accord- 
ing to whether the lens be removed through the natural pupil without 
excising a piece of iris-tissue, or through an artificial pupil made by 
iridectomy. A full description of these operations will be found in any 
text-book on ophthalmology. No operation for the extraction of cata- 
ract should be done by any save an ophthalmic surgeon, and then only 
after the most careful investigations of the functions of the eye and the 
general health of the patient. 
Panophthalmitis . 
Panophthalmitis, or phlegmonous inflammation of the eyeball, is a 
somewhat complex process in which all the tissues of the eye become 
involved in the purulent process. While usually traumatic, in origin 
from some laceration or rupture of the eyeball, the germs being probably 
introduced at the time of the injury, it frequently arises from abscess of 
the cornea, which perforates into the anterior chamber, or is due to the 
propagation of the purulent process from a suppurative choroiditis, which 
may be thrombotic or metastatic in origin. 
Symptoms.—The course of the disease is rapid and severe, and the 
symptoms resemble those of orbital cellulitis. The eyelids become red 734 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
and swollen ; the conjunctiva is injected and chemotic, especially around 
the corneal margin. There may be a thin purulent discharge from the 
lids. If the cornea be clear, the aqueous is seen to be hazy, and there 
may be a deep yellow reflex from the fundus. The symptoms increase 
rapidly in severity : the cornea becomes infiltrated; the orbital tissue 
takes on a hard and brawny condition; the eye begins to protrude, and 
is more or less immovable; there are rapid loss of sight, high fever, 
intense pain, sometimes leading to nausea and vomiting, and at times 
great general prostration. The purulent process tends to perforate for- 
ward through the cornea or in the ciliary region. If the process begin 
in a purulent keratitis, the cornea generally ruptures early in the course 
of the disease, and the decomposed contents of the eyeball early find an 
exit through the corneal abscess, and the pain is therefore less severe. 
Panophthalmitis always ends in destruction of the eye, and hence all treatment 
should be directed toward hastening the suppurative process. The surgeon can 
materially assist in this object by incising the cornea freely, and then eviscerating 
the entire contents of the eye by means of a sharp spoon, leaving the sclera as a 
shell behind. The hollow sclera should then be freely irrigated with a warm 
bichloride solution several times daily, while hot fomentations are kept constantly 
on the closed lids. This operation of evisceration is the only safe surgical proce- 
dure in panophthalmitis. Enucleation of an eyeball should never be done in this 
disease until all signs of purulent infection have vanished, owing to the danger of 
inciting purulent meningitis by extension of the process to the brain through the 
medium of the sheath of the optic nerve. 
Tumors of the Iris.—Neoplasms in the iris are relatively rare. 
Cyst of the iris is comparatively a rare affection. It is either the 
result of sacculation in consequence of injury or operation, or it arises 
from the proliferation of cells introduced into the anterior chamber, as, 
for instance, from the introduction of an eyelash through a wound in the 
cornea and iris. A cyst may be situated in the substance of the iris or 
may consist in a simple lifting up of the epithelial layer. 
Intraocular Tumors. 
It is lined with cells and grows gradually, pressing back the iris and ultimately 
disturbing the vision. It is always more or less translucent. If not removed the 
eye will be lost by general inflammation. 
The treatment should be complete excision, and should be left to 
the hand of an ophthalmic surgeon. 
Ncevi, or simple melanomata, are always congenital, and present the 
appearance of small black patches or elevations which remain stationary 
and cause no irritation. They consist of a circumscribed hyperplasia-of 
the uncolored and pigmented stroma-cells of the iris. They are best 
left undisturbed. 
Tubercles of the iris, or granulomata as they were formerly termed, 
are now much better understood, and their nature is perfectly identified 
by recognizing within them the characteristic bacilli. 
They appear as grayish-red irregular nodules, generally at the periphery of 
the iris, and are accompanied by circumcorneal injection, haziness of the cornea 
or aqueous humor, photophobia, lachrymation, occasionally by some pain and dis- 
turbance of vision. Their progress may be either rapid or slow. They may mul- 
tiply and fill the anterior chamber, causing increase of the intraocular tension, 
and eventually perforation of the eyeball, or they may grow very slowly, become 
arrested, and finally shrink, inducing phthisis bulbi. When the tubercles are mul- INTRAOCULAR TUMORS. 
735 
tiple there is danger of general infection, and the eye should at once be enucleated. 
If the tubercle be isolated, an attempt maybe made to excise it, trusting to its non- 
recurrence. Where, however, such a tuberculous deposit appears in the iris, its 
existence may be suspected in the ciliary body or choroid. 
Sarcoma is extremely rare as a primary affection of the iris, and is 
generally melanotic in character. There is usually but a single tumor, 
and it may grow from any part of the iris and may occur at any age. 
It appears as a small, rounded, dark-brown or yellowish-brown elevation, 
which may remain stationary for a time, or may grow rapidly and ex- 
tend into the anterior chamber, perforate the cornea, and protrude as a 
fungous mass. If the sarcoma be of the white variety, its growth is 
usually very slow. 
The ihag-nosis between a solitary tubercle and a sarcoma is founded 
upon the irregular, yellowish-red appearance of the former, with injection 
of the neighboring parts of the eyeball, while sarcoma is more smooth 
and regular in outline, and less likely to be accompanied by ciliary in- 
jection. 
Treatment.—When small, a sarcoma may be removed by excision, 
including a large piece of the iris. This is a very delicate operation 
which should be left to the ophthalmic surgeon, and it should never be 
undertaken unless it be tolerably certain that the neoplasm is confined 
to the iris. Where the growth has extended to other tissues of the eye- 
ball or has perforated the cornea, enucleation should be immediately 
performed. 
Among the rarer neoplasms occurring in the iris should be mentioned lymph- 
omata, which have been met with in leucocythsemia, and lepra, which occurs in the 
tuberous form of the leprous dyscrasia. 
Tumors of the Ciliary Body.—Morbid growths of primary origin 
in the ciliary body are very rare, and their exact nature is difficult to 
determine. Most of the tumors met with in this region have extended 
to it either from the iris on the one hand or the choroid on the other. 
The SYMPTOMS of such a growth are but slightly marked. There 
would be slight local hypersemia, a slight bulging in the ciliary region, 
with more or less marked discoloration of the sclera, slight bulging of 
the iris toward the cornea, and perhaps slight dislocation of the lens. 
Sarcoma of the ciliary body is about the only morbid growth met with 
here, though deeply pigmented epithelial growths have been mentioned 
by Collins. 
When a sarcoma of the ciliary body has acquired any size it can be observed 
protruding into the anterior chamber. The iris is pushed aside from its ciliary 
insertion by a dark-brown tumor, which encroaches on the field of the pupil and 
extends backward beyond the plane of the lens. The only treatment is immediate 
enucleation of the eyeball. 
Tumors of the Choroid.—Tubercles of the choroid are found chiefly 
in cases of acute miliary tuberculosis, and especially in cases of tuber- 
cular meningitis. They appear ophthalmoscopically as distinct whitish- 
yellow spots or nodules in the stroma of the choroid, grouped around the 
region of the optic nerye and macula. They vary greatly in size, and 
may aggregate into larger masses. They may or may not be accompanied 
by retinitis or neuro-retinitis. 
Solitary tubercle of the choroid is very rare, and from its size simulates the 736 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
appearance of sarcoma. In disseminate tubercle of the choroid there are rarely 
any symptoms, and the patients generally die of the general disease before the 
disease of the eye has advanced very far. No treatment is of any avail. Solitary 
tubercle always tends to destroy the eye and penetrate the sclera, and here enucle- 
ation of the eyeball is the only proper treatment. 
Sarcoma of the choroid is by tar the most frequent morbid growth 
met with in this membrane. It is most frequently of the pigmented 
variety (melano-sarcoma), but is sometimes free from pigment (leuko- 
sarcoma). A mesh of small, dark vessels forms at some spot in the 
retina, and the latter shows a gray opacity. If it occur near the macu- 
la lutea, vision is impaired at once. As the tumor grows its elevation 
may be made out, but often the retina becomes detached over it and 
obscures the outline. If of the pigmented variety, however, its dark 
color shows through. 
As the growth continues and the tumor advances toward the lens, there may 
be a yellowish reflex from the fundus, and strong focal illumination will sometimes 
reveal its vascularity. The intraocular tension is usually increased, and if this be 
marked there is generally more or less pain. As the tumor grows it may extend 
in every direction, and the chief danger lies in its extension backward through the 
sheath of the optic nerve or through the lymph-channels along the vortex veins 
into the orbital tissue. In this latest stage there is usually some ciliary injection 
and some sign of intraocular inflammation, and the iris may be dilated ad maxi- 
mum as in acute glaucoma. 
The symptoms are almost entirely ophthalmoscopic. 
Treatment.—As soon as the diagnosis is made the eye should be at 
once enucleated, and the optic nerve should he divided as far back as 
possible, near the apex of the orbit, in order, if possible, to include all 
the foci of disease in the enucleation. 
Tumors of the Retina.— Glioma is a malignant tumor of the retina, 
and is found exclusively among young children and youths, the great 
majority of cases occurring in children under ten years of age. It is a 
comparatively rare disease. 
The ophthalmoscope shows a yellowish-white growth at the bottom of the eye, 
which is covered by minute blood-vessels, with here and there a minute hemor- 
rhage. At first there is neither increase of tension nor pain, but as the tumor 
grows the eye may become hard and the circumcorneal veins injected. The 
growth involves the choroid and ciliary body, and may extend to the iris and enter 
the anterior chamber. Later the cornea may slough, episcleral growths appear, 
and the orbit become invaded. At this stage the tumor grows with great rapidity, 
and extends in every direction, notably backward through the optic foramen and 
deep sinuses to the brain. Metastatic growths also appear in various parts of the 
body. Microscopically, the growth appears to originate in the outer or inner 
nuclear layer, and shows a delicately fibrillated reticulum, with numerous blood- 
vessels and small round cells with large nuclei. Very often the tumor shows the 
structure of a mixed growth, and is then called a glio-sarcoma. Sight is lost early 
in the course of the disease. 
Treatment.—Enucleation of the eye should be advised as early as 
possible as the only means of preventing death, and the optic nerve 
should be divided as near the apex of the orbit as possible. If the 
growth have invaded the orbit, the entire contents of the orbit, including 
periosteum, must be removed. 
Injuries to the Orbit. 
Injuries to the Orbital Margin.—Contusions of the orbital margin 
are frequently followed by more or less extensive extravasations, which [XJURIES TO THE ORBIT. 
737 
are subcutaneous, subperiosteal, or subaponeurotic, and may extend in 
every direction under the skin, and even under the conjunctiva. If an 
artery of any size have been ruptured, the extravasated blood forms a 
pulsating tumor, which may render the diagnosis extremely difficult. 
Blows upon the margin of the orbit frequently involve the supraorbital 
and infraorbital nerves, and to the laceration of these nerves has been 
attributed the amaurosis which has been known to follow such injuries. 
This blindness is due to paralysis and subsequent atrophy of the optic 
nerve, and the real cause is probably a fissure or fracture of the orbit 
extending backward to the optic foramen. 
Fracture or dislocation of the malar bone may occur from falls or 
blows upon this bone. Such an accident usually fractures the zygoma, 
and sometimes opens the suture between the malar and superior maxil- 
lary bones, and may cause extensive hemorrhage into the orbit. Anaes- 
thesia of the infraorbital nerve from laceration in its bony canal, and 
annoying diplopia from injury to the inferior oblique muscle, are occa- 
sional consequences of such fractures. 
Fractures of the bones of the orbit may be either direct or indi- 
rect, and may be caused by blows or falls on the head or face, gunshot 
wounds, and penetrating wounds of the orbit, with or without lodgement 
of a foreign body. 
The usual symptoms are hemorrhage and displacement of the eye- 
ball, and, in rare instances, crepitus. 
Gunshot wounds of the orbit complicate the diagnosis, on account 
of injury to the contents of the orbit. When sudden and complete 
blindness occurs after such an injury and the eyeball appears intact, it 
may be due to laceration or rupture of the optic nerve, or to rupture of 
the choroid through the region of the macula. 
Fractures of any one of the four walls of the orbit may occur alone or in con- 
nection with fracture of the other walls. If the inner wall be fractured, there will 
be displacement of the lachrymal bone, bleeding from the nose, and emphysema 
of the orbital tissues and eyelids. 
If the floor of the orbit be fractured, the symptoms are hemorrhage into the 
orbit, bleeding from the nose or mouth, the blood coming from the maxillary 
antrum, emphysema of the orbit, and displacement of the eyeball by the broken 
fragments. Such a fracture involves both the malar and superior maxillary bones. 
Fracture of the roof is the most serious of all injuries to the orbit. The objec- 
tive symptoms are usually wanting unless the superior orbital margin is involved. 
When cerebral symptoms occur, they may be due to pressure or infection, and 
there will be pain, vertigo, delirium, paralysis, and coma. The symptoms may be 
long delayed, but the case is almost certain to end fatally. Death may result from 
meningitis, or abscess of the brain, or thrombosis of the lateral sinus. 
In those cases which do not terminate fatally the most serious symp- 
tom which may occur is blindness. If the loss of vision be unilateral, it 
always occurs in the eye on the injured side, and is due to laceration of 
the optic nerve by the fractured bones or to atrophy of the nerves by 
pressure from extravasated blood. If the blindness be bilateral, the frac- 
ture extends into the middle fossa of the skull, and the loss of vision is 
due to direct laceration of the optic chiasm or optic tract, or to compres- 
sion of the chiasm or tract by an extensive blood-clot. The ophthalmo- 
scopic symptoms in such cases would be venous hypersemia, arterial 
ischaemia, and hemorrhages on the disk and in the retina, followed by 
neuro-retinitis and atrophy. 738 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
Treatment.—This is to be conducted on general surgical principles. 
All perfectly loose bits of bones are to be removed, and the track of the 
wound should be carefully irrigated with some antiseptic solution. If 
abscess of the orbit develop, it must be laid open and free drainage 
maintained. If the eyeball be ruptured or destroyed, it must be removed 
at once. If the roof of the orbit be perforated and brain-symptoms 
appear, further exploration of the wound may be indicated, and should 
be carried out under the strictest antiseptic precautions. 
Injuries of the Soft Parts of the Orbit.—Under this head are in- 
cluded the connective tissue of the orbit, the muscles, eyeball, optic 
nerve, and lachrymal gland. Foreign bodies, even of large size, may 
enter the orbit and pass entirely out of sight, and are often extremely 
difficult to find. If they do not destroy the eyeball or penetrate some 
one of the neighboring cavities, they may remain for a long time undis- 
covered. Whenever such foreign bodies can be seen or felt they should 
be immediately removed and the wound treated antiseptically. If the 
case be seen within a short time after the receipt of the injury, careful 
probing will often reveal a small body. 
One of the most constant symptoms of the presence of a foreign body is dis- 
placement or limited motility of the eyeball. A iater symptom is disturbance of 
vision caused by pressure on the eyeball or optic nerve. If the foreign body be 
sought for and found immovable, it has probably perforated one of the walls of the 
orbit, and great care must then be taken in its removal, especially if the roof have 
been perforated. If the case be an old one and the eyeball have become blind and 
atrophied, no attempt should be made to remove the foreign body unless the eye is 
first enucleated, as the foreign body is certainly encapsulated and practically in- 
nocuous. The toleration of the presence of foreign bodies of large size manifested 
by the orbit is sometimes extraordinary. 
Laceration or rupture of the ocular muscles maybe due to traumatism. 
There will be disturbance of motility in one or more directions; and if 
all the muscles are ruptured, the eyeball will be dislocated forward 
entirely outside the eyelids. The internal rectus muscle is the most 
frequently injured. If all the muscles are ruptured and the eyeball be 
displaced outside the lids, an attempt should be made to replace it by 
means of oiled spatulas introduced beneath the lid and steady pressure 
backward. If, however, the optic nerve have been ruptured, the eyeball 
should be at once enucleated. 
Hemorrhage into the Orbit.—Extravasations of blood within the orbit 
may come from ruptured blood-vessels in the orbit or from vessels out- 
side of the orbit. They may be either spontaneous or traumatic, the 
latter being the most frequent. Blood may be extravasated beneath the 
periosteum, or in the orbital cellular tissue, or within the capsule of 
Tenon. 
The causes are haemophilia, scurvy, disease of the walls of the vessels, 
or violent coughing or retching, and, finally, traumatism of any kind. 
The symptoms are extravasation of blood beneath the conjunctiva 
and into the tissue of the eyelids, exophthalmos, and more or less limita- 
tion of motility of the eyeball. The exophthalmos is usually directly 
forward. Hemorrhage into the orbit after blows or falls upon the head 
has prognostic significance as a sign of the presence of a serious injury, 
as there is probably fracture at the base of the skull. 
The usual course of an orbital hemorrhage ends in absorption of the extrava- INJURIES TO THE ORBIT. 
739 
sated blood in from three to six weeks, but if it have been very extensive, with 
excessive protrusion of the eyeball, the latter may be destroyed by neuro-paralytic 
keratitis and abscess of the cornea. 
Treatment.—Slight hemorrhages usually disappear spontaneously. 
The application of iced compresses and a firm bandage generally suffices 
for the more serious cases. If there be much pressure on the eyeball and 
marked exophthalmos, the blood may be let out through a free opening 
with a broad bistoury; but this is rarely necessary, and should always 
be done under the strictest antiseptic precautions. 
Orbital cellulitis is an inflammation of the fatty and cellular tissue of 
the orbit, and may be acute, subacute, or chronic in character. It may 
be unilateral or bilateral. It may undergo resolution, and disappear 
without leaving any lasting trace of its presence; but in the great ma- 
jority of cases it ends in suppuration and the formation of an abscess. 
Etiology.—It may be traumatic or idiopathic in origin. If it be 
due to traumatism, it may arise from fracture of the bones of the orbit, 
from penetrating wounds with or without the presence of a foreign body, 
or from some surgical operation on the orbit. 
The idiopathic causes may be long-continued exposure to cold, periostitis, 
the exanthematous fevers, meningitis, through the medium of thrombosis of the 
cavernous sinus or ophthalmic veins; facial erysipelas, extension of the inflam- 
matory process from diseased teeth in the upper jaw, suppuration in the ethmoid 
cells or sphenoidal sinus; metastatic inflammation due to general pyaemia or puer- 
peral septicaemia, panophthalmitis; and in rare instances inflammation in and 
around the lachrymal gland. 
Symptoms.—In mild cases there are dull pain in the orbit, slight 
swelling of the lids, and slight divergence and protrusion of the eyeball. 
In the more severe cases the attack is usually ushered in by a chill, fol- 
lowed by fever, deep-seated pain, headache, more or less immobility of 
the eyeball, swelling and discoloration of the lids, hypersemia and che- 
mosis of the ocular conjunctiva, exophthalmos, defective vision due to 
neuro-retinitis, anaesthesia, ulceration and suppuration of the cornea, 
ending in panophthalmitis. 
Treatment.—If the case be of the mild type, with little or no con- 
stitutional disturbance, two or three leeches should be applied to the 
brow or temple, and frequently changed hot compresses to the closed 
lids, and iron and quinine should be administered. If the case be of 
the severe phlegmonous type, six or eight leeches should be applied to 
the brow and temples, and the hot compresses must be continually em- 
ployed and frequently changed. If the swelling and exophthalmos be 
marked, free incisions must be made into the orbital tissue, through the 
conjunctiva, at the point of greatest tension, with a straight, narrow 
bistoury, kept parallel with the wall of the orbit; and these incisions 
must be kept open by a large probe, with frequent irrigation with a 
warm solution of mercuric bichloride (1 : 2000). At the same time the 
patient’s strength must be supported by stimulants, quinine, mineral 
acids, and opiates. If panophthalmitis supervene, the eyeball must be 
freely opened through the cornea and the contents evacuated by pressure 
and a blunt spoon. This is called evisceration of the eyeball. When all 
signs of inflammation have subsided in the orbit, the blind or atrophied 
eyeball may then be removed by enucleation. 
The operation of enucleation is done as follows : The patient must be 740 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
anaesthetized and the lids held open by a spring speculum. The eyeball 
must be grasped bv fixation-forceps, and the ocular conjunctiva is then 
to be incised all round the corneal margin with blunt-pointed scissors. 
The divided conjunctiva must then be pushed away from the eyeball 
with the scissors and a strabismus-hook thrust under the four straight 
muscles and the two oblique muscles in turn, and each is divided close 
to its tendinous insertion in the eyeball. It is well to leave a small 
knob of tendon of the external rectus attached to the eye, so that it can 
be seized with forceps and the eye easily adducted. All adhesions 
between eyeball and the oculo-orbital fascia are then to be divided with 
the same blunt-pointed scissors. The eyeball must then be forcibly 
adducted, and a large pair of blunt-pointed, broad-bladed scissors, 
curved on the flat, must be introduced on the temporal side between the 
eyeball and orbital wall, and, with the blades slightly opened, carried 
backward until the apex of the orbit is reached. A little manipulation 
will engage the optic and ciliary nerves between the blades of the scis- 
sors, and they are then to be divided as far back of the eyeball as possi- 
ble. As soon as all bleeding has ceased the ocular conjunctiva is to be 
brought together by a single stitch which covers all the remaining con- 
tents of the orbit, and a pressure bandage is then applied. This must 
be removed the next day, and the orbit thoroughly irrigated with a 
warm antiseptic solution. The bandage must be renewed for three or 
four days, and may then be discarded. The stitch may be removed at 
the end of a week. 
Pulsating Exophthalmos. 
Pulsating exophthalmos is a diseased condition, generally the result 
of traumatism, characterized by the following complex group of symp- 
toms : (1) Protrusion of the eyeball forward, and usually a little down- 
ward and outward; (2) peculiar audible sounds over the region of the 
orbit and over a more or less extensive region of the skull; (3) a dis- 
tinct pulsation demonstrable in the eyeball or over any spot in the region 
of the orbital aperture. 
The lesion is situated either in the orbit or in the cavity of the skull. If in 
the orbit, it may be a true aneurism or a spurious aneurism. The latter may be dif- 
fuse or circumscribed, or it may communicate with both artery and vein and form 
an arterio-venous or varicose aneurism. If the lesion be in the cavity of the skull, 
it may be an aneurism of the ophthalmic artery at its origin from the internal caro- 
tid, or an aneurism of the carotid artery itself, or an arterio-venous aneurism by a 
rupture of the internal carotid artery in the cavernous sinus. 
Symptoms.—These are exophthalmos, more or less marked; hard, 
dense swelling of the upper lid, the skin being livid and shining and the 
veins enormously swollen ; loss of the tarso-orbital fold, and sometimes 
eversion of both lids; discoloration and chemosis of the ocular conjunc- 
tiva ; slight cloudiness of the cornea, with tendency to ulceration ; a 
hypersemic, dilated, and sluggish iris. The eyeball can be replaced by 
pressure in the orbit, but the protrusion recurs as soon as the pressure is 
relaxed. The pulsation of the eyeball is sometimes visible as well as 
tangible, and is rhythmical with the pulse. In addition to the pulsation, 
the fingers when laid upon the eyeball will feel a more or less distinct 
thrill. Sometimes a soft, compressible, pulsating tumor may be felt PULSATING EXOPHTHALMOS. 
741 
upward and inward from the eyeball. If a stethoscope be applied to the 
eyeball or the upper margin of the orbit, a more or less distinct blowing 
noise is heard. By compression of the common carotid artery in the 
neck on the corresponding side the pulsation and noise either imme- 
diately cease or become much less marked. The retinal veins are enor- 
mously dilated and pulsating, while the arteries are much reduced in 
calibre, and there may be all the signs of papillitis. The vision may be 
greatly or not at all atfected. The subjective symptoms are severe pain 
in the orbit and head, and a constant roaring or buzzing sound, which is 
very annoying and is often accompanied by vertigo. 
Etiology, Diagnosis, and Prognosis.—The spontaneous cases 
occur very suddenly, are more common among females than males, and 
the causation is unknown unless we attribute it to extensive disease of 
the walls of the blood-vessels. In the traumatic cases any injury which 
is likely to produce a fracture at the base of the skull may cause pul- 
sating exophthalmos, and in many of these cases the progress of the dis- 
ease is very insidious and the. symptoms are slow in developing. Little 
is known of the true pathology of pulsating exophthalmos, for even at 
the autopsy the true nature of the lesion cannot be determined. 
It is always difficult, and sometimes impossible, to distinguish between the dif- 
ferent varieties of pulsating tumors in the orbit. The most important point to 
determine is whether the pulsating exophthalmos depends on the presence of a 
benign or malignant tumor, on an aneurism, or on inflammation of the sinuses. 
Vascular tumors are more resistant to pressure than aneurisms, and their position 
in the orbit is usually out of the line of the axis, and their development much 
slower than that of an aneurism. Malignant tumors of the orbit with pulsation 
and exophthalmos are usually of rapid growth. Pulsating angeiomata are less 
painful than malignant tumors, and expand more easily after removal of the 
pressure. Mixed tumors, partly angeiomatous and partly aneurismal, occur in the 
orbit, and may be confounded with the pulsating exophthalmos. The plex- 
iform angeiomata are essentially venous in character, consisting of a convoluted 
mass of distended veins held together by loose connective tissue. Here there is no 
pulsation and no bruit. 
Another form of vascular tumor met with in the orbit is a very rare 
condition known as the pulsating encephaloid tumor. When a soft orbital 
tumor is found to be fluctuating and very vascular, with marked pulsa- 
tion, it is almost certainly malignant and sarcomatous. It has a smooth 
surface like a true pulsating exophthalmos, but it does not yield as readily 
to pressure under the fingers. Multiple pulsating growths in and about 
the orbit would indicate their malignant character. A true pulsating 
exophthalmos occurs most frequently at the upper and inner side of the 
orbit. 
When we come to consider those cases in which the lesion is posterior to the 
orbit, the diagnosis becomes extremely difficult. Most of the cases of pulsating 
exophthalmos consequent on some extraorbital lesion have been found to be due 
to a rupture of the internal carotid within the cavernous sinus, and are usually 
traumatic in origin. They may be divided into two classes: (1) Those in which 
all the symptoms are fully developed within twenty-four hours of the receipt of the 
injury; (2) those in which months elapse before all the symptoms are developed. 
The latter class is much the more numerous. The traumatism may be direct, 
as from a gunshot wound, or indirect, from fracture at the base of the skull and 
injury of the artery and sinus by a splinter of bone. In these cases the immediate 
consequence is an increase of ocular pressure, with signs of stasis, first seen in the 
superior ophthalmic vein. 742 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
Treatment.—The two chief surgical methods of treatment are com- 
pression of the common carotid artery and ligation of the same artery. 
Compression may be either instrumental or digital, the latter being 
the more frequently employed. It seems better in every case of pulsating 
exophthalmos to begin the treatment by compression, which of course at 
first must be intermittent. In idiopathic cases this compression will often 
alone effect a cure. In traumatic cases the pressure must be continuous 
and kept up for several hours. 
The compression of the artery against the vertebral column is best done at the 
level of the top of the thyroid cartilage at the anterior edge of the sterno-cleido- 
mastoid muscle. The advantage of compression is that it affords time for the full 
development of the collateral circulation, and this method is more likely to succeed 
in the idiopathic cases because the arterial wall is almost always diseased and fre- 
quently the seat of aneurismal dilatation, whereas in traumatic cases the walls of 
the ruptured artery are healthy and the conditions are not favorable for coagula- 
tion of blood in the artery. If lasting success is to be obtained in the traumatic 
cases by digital compression, this must be continued uninterruptedly from three to 
six hours at a time. 
Ligation of the common carotid artery gives the most satisfactory re- 
sults and is to be done in the usual place and manner. As a rule, the 
pulsation and bruit disappear immediately, the tumor collapses, the ex- 
ophthalmos diminishes, the swelling of the lids and the chemosis vanish, 
the motility of the eyeball returns, and vision is gradually restored. 
Faint subjective sounds may return after a few hours, but the cure is 
generally complete in six weeks. In a small number of cases the symp- 
toms return after ligation, sometimes on the same side, more rarely on 
the opposite side, and in these cases we may ligate the external carotid 
of the same side or the common carotid of the opposite side. In pul- 
sating malignant tumors ligation of the common carotid artery has proved 
entirely unsuccessful. 
In pulsating angeiomata ophthalmic surgeons prefer to employ complete ex- 
tirpation of the tumor in situ. If the angeioma be of moderate size, it might be 
well to try galvano-puncture, which is a perfectly safe procedure. This method 
also promises good results in cirsoid aneurism and in nsevus of the orbit. 
In malignant pulsating tumors of the orbit complete extirpation of the mass is 
the only method which promises any satisfactory results. 
Tumors of the Orbit. 
Tumors of the orbit are divided into two elasses : (1) Those which 
originate in the orbit, either in the orbital tissue itself, the sheath of the 
optic nerve, or the periosteum of the bony walls; (2) those which arise 
in some one of the neighboring bony walls or sinuses, and which involve 
the orbit secondarily. This distinction is important, both from the diag- 
nostic standpoint and from the side of operative interference, for the 
location and extent of an orbital growth frequently decide not only 
the question of an operation, but also its nature and extent. Many 
of the so-called orbital tumors arise in the ethmoid cells, the sphenoid 
antrum, the frontal sinus, the nasopharynx, or the maxillary antrum. 
The growth of these tumors is generally slow and insidious, though 
occasionally it is exceedingly rapid. 
Orbital tumors may be either fluid or solid. The former almost 
always arise in the frontal sinus or ethmoid cells, and contain pus or TUMORS OF THE ORBIT. 
743 
mucus. The latter are either solid or densely gelatinous, and are 
always malignant in character. 
Tumors originating in the Orbit.—These include solid neoplasms, 
cysts of all kinds, and sanguineous tumors, classed under the collective 
names of orbital aneurisms. Tumors of the orbit are relatively frequent, 
forming nearly 50 per cent, of all orbital diseases. 
Symptoms and Diagnosis.—The most marked symptom of orbital 
tumors, which is only absent in the rarest cases, is exophthalmos. The 
degree of protrusion of the eyeball enables us to draw some conclusions 
as to the extent of the growth. The direction in which the protrusion 
occurs is of importance in determining the location of the tumor, it 
being usually on the opposite side of the orbit from the protrusion. The 
exophthalmos is occasionally accompanied by rotation of the eyeball, 
and generally by more or less marked limitation of its motility. Di- 
plopia generally results from the displacement of the eyeball. Another 
symptom which accompanies tumors of the upper part of the orbit is 
ptosis. 
Still another symptom which is occasionally met with is pulsation of the eye- 
ball or orbital contents, which may be felt or heard, and sometimes seen. It occurs 
in angeiomata, encephalocele, angeio-sarcoma, and in all forms of orbital aneur- 
ism. Digital examination will sometimes aid us materially in forming an opinion 
as to the situation, extent, shape, resistance, and movability of the tumor, assisted 
by puncture with needle or trocar or by removing a small piece of the supposed 
tumor for microscopical examination. Disturbances in the sensory nerves and 
anomalies of circulation will aid us in diagnosis. Spontaneous pain, when pres- 
ent, is generally constant, but it is occasionally intermittent and sharp, like ciliary 
neuralgia. 
The disturbances of vision produced by an orbital tumor are of much the same 
nature as those met with in orbital cellulitis, and vary in character and intensity. 
There may be loss of central vision, central scotomata, narrowing of the visual 
field, and more or less complete amaurosis from optic neuritis or from an atrophy 
of the optic nerve. At first the ophthalmoscopic examination is negative, but as 
the pressure from behind continues, and the obstruction to the return circulation 
becomes more complete, the retinal veins become engorged, the arteries become 
narrowed, and the picture becomes finally that of papillitis, with hemorrhages into 
the retina, retinitis, and atrophy of the optic nerve. Occasionally we meet with 
primary atrophy of the nerve without any signs of neuritis. In some cases a 
neuro-paralytic keratitis is developed, with ulceration, abscess, and perforation of 
the cornea, due to interference with its nutrition by tbe pressure in the orbit. 
Though orbital tumors generally tend to grow outward and forward, they may 
endanger life by extension backward through the optic foramen or superior orbital 
fissure to the middle fossa of the skull, or they may penetrate through the roof of 
the orbit by caries and absorption into the anterior fossa, and destroy life in 
this way. 
In aggravated cases the eyeball is protruded almost entirely outside the eyelids, 
the latter become enormously congested and distended, and the growth extends 
beyond the limits of the orbit upon the cheek, temple, and forehead. 
Topographically, orbital tumors may be divided into four classes— 
viz. (1) Those which arise in the orbital cellular tissue, and which form 
the great bulk of all the tumors ; (2) tumors originating in the lachry- 
mal gland, and these have been considered under the head of Diseases 
of the Lachrymal Apparatus ; (3) tumors originating in the optic nerve; 
(4) tumors arising in the bony walls of the orbit. 
Prognosis as to Recurrence.—When a morbid growth in the 
orbit has been removed the chances of its return are much smaller if it 
have been found encapsulated; and when in such a case the orbit again 744 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
becomes filled, we must assume either a nidus of disease left behind 
or a new secondary tumor. The size and rapidity of growth of a tumor 
are usually indicative of its nature. As a rule, the more developed the 
cellular element of a tumor is, the more rapidly does it grow. When 
such a tumor recurs after extirpation, the secondary growths are always 
richer in cells than the original tumor and grow much more rapidly. 
Tumors which Arise in the Orbital Cellular Tissue.—Cysts.—This 
class includes encephalocele, extravasation-cysts, pigment-cysts, exuda- 
tion-cysts, retention-cysts, dermoid cysts, echinococci, and cysticercus. 
Encephalocele is a hernia from the brain into the orbit through an opening 
in the suture between the ethmoid and frontal bones, the lachrymal bone being 
generally entirely absent. It is always congenital. The amount of displacement 
of the eyeball depends on the position of the hernial ring. There may or may not 
be pulsation in the tumor. It increases rapidly in size and life is prolonged 
merely for a few months. These cases do not admit of any treatment. 
Extravasation-cysts include the blood-cysts, haematocele, and haematoma, and 
also the pigment-cysts or melanotic cysts. Very few cases of true blood-cysts of 
the orbit are on record, for most cases of cystic formation in the orbit with bloody 
contents have been originally instances of dermoid cysts in which exploratory 
punctures have produced a hemorrhage. 
Exudation-cysts.—Of this class there is but a single variety in the orbit, the 
hygromatous degeneration of the tendinous bursae. 
Retention-cysts, ox follicular cysts, form a large class, and include the atheromata, 
steatomata, and cholesteatomata. They are simply varieties of true dermoid 
cysts. 
Dermoid cysts are foetal structures resulting from the invagination of the exter- 
nal blastodermic membrane. They are round, with thick, vascular walls lined with 
endothelium, and may be unilocular or multilocular. They increase slowly in size, 
and their contents consist of epithelium or epidermis, hairs, fluid fat and fat- 
crystals, fluid, gelatinous, or solid constituents, chalky deposits, and even skin 
and teeth. 
Echinococcus cysts are surrounded by a framework of connective tissue, and the 
cavity is filled by the mother-cyst, in which are the cysts of the third generation 
floating in a liquid. They may extend to the frontal sinus, and even into the cavity 
of the skull. Ciliary neuralgia is almost a constant symptom in this disease. 
Cysticercus in the orbit is very rare. The sac is surrounded by a very thick 
connective-tissue envelope. The symptoms are fluctuation, redness and sensitive- 
ness of the skin of the lids, pain, and displacement of the eyeball. 
An encephalocele is distinguished by its congenital origin, location, 
bilateral character, and pulsation. All the cystoid tumors are charac- 
terized by fluctuation, and in doubtful cases an exploratory puncture 
would aid in the diagnosis, especially if assisted by chemical and micro- 
scopical examination of the contained fluid. 
Treatment.—The treatment of all these cystoid tumors should be 
surgical, and the operation should be the total excision of the cyst. The 
eyeball should be left intact, unless it be found that the cyst cannot be 
removed entire without first enucleating the eye, in which case it must 
be sacrificed, even though still capable of useful vision. 
Angeiomata.—Simple angeiomata include the nsevus maternusand the 
teleangiectasise of the lids and orbit. They are rarely met with in the 
orbit alone, the eyelids and neighboring skin being usually involved. 
They are always congenital, and appear as soft, slightly compressible 
tumors on one side of the eye. 
Cavernous angeiomata include the erectile tumors and the aneurisms 
by anastomosis. They are met with in all parts of the orbit, but are TUMORS OF THE ORBIT. 
745 
more frequently found behind the orbit, and are surrounded by a thick 
capsule of connective tissue. They pulsate spontaneously, are firmly 
elastic, of slow development, and generally painless. 
The prognosis is favorable, and they occasionally heal spontaneously. 
The chief danger lies in loss of vision from pressure on the optic nerve. 
Treatment.—The treatment should always be by operation, and 
total extirpation of the tumor gives the best result. In some cases of 
small angeiomata and of teleangiectasia electrolysis may be tried, and 
has been known to produce a gradual diminution in the size of the tumor. 
The electrolysis must be repeated a number of times at short intervals. 
Lipoma, of the orbit, unconnected with the eyelids, is a rare disease, 
and must be differentiated from general hypertrophy of the fatty con- 
nective tissue of the orbit. 
Enchondroma.—The cases hitherto reported of enchondroma of the 
orbit are described as tumors of a cartilaginous character developed in 
the fatty tissue of the orbit, and by Berlin have been classed among the 
cylindromata (probably endotheliomata). 
Orbital Tumors of Epiblastic Character.—Under this general classi- 
fication have been grouped three different varieties of tumor which have 
certain general resemblances—viz. epithelial carcinoma, adeno-carci- 
noma, and adenoma. Strictly speaking, none of these tumors arise in 
the orbit, but all start from the lids, the lachrymal gland, or some one 
of the neighboring sinuses. 
Orbital Tumors of the Connective-tissue Type.—These are solid, with 
more or less uneven surface, and with neither fluctuation nor pulsation. 
They are neither compressible nor very hard. They may involve one 
or more of the neighboring cavities, but are much more likely to orig- 
inate in some one of the neighboring cavities and extend to the orbit 
secondarily. 
The microscope alone can establish the diagnosis as to the true nature of such 
a tumor. The younger the patient is, and the more numerous the cellular ele- 
ments are, the more rapid is the growth of the tumor and the greater certainty 
there is of a return. In cases of pigmented tumors the diagnosis must largely 
depend on the dark color of the growth, and even then such a tumor may be con- 
founded with a cavernous angeioma. These melanotic tumors show a strong tend- 
ency to extend toward the intracranial cavity and to the development of metastatic 
growths in various parts of the body. 
Treatment.—The treatment of all these tumors consists in complete 
extirpation at the earliest possible period. 
Tumors which Arise from the Bony Walls of the Orbit.—Cysts 
of the Orbital Walls.—Echinococcus and serous cysts, as well as chole- 
steatomata of the orbital walls, have probably originated as cysts of the 
frontal sinus. 
Osteosarcoma.—Almost the same statement may be made of the 
so-called osteosarcoma of the orbital walls. The participation of these 
bony walls in the process is generally only part of very extensive disease 
of the other bones of the skull, and it is impossible to point out the 
place of origin of such growths. 
Osteoma of the Orbit.—Under the general head of osteoma are classed, 
for convenience, osteophytes, periostoses, hyperostoses, and exostoses, as 
well as true ivory osteomata. ( Vide Vol. I. Chap. XXVI.) 746 
INJURIES AND DISEASES OF THE EYE AND ORBIT. 
These bony tumors are met with most frequently in the upper and inner angle 
of the orbit, and generally in the frontal bone. They may be unilateral or 
bilateral, and are generally hemispheroidal in shape, with a broad base of attach- 
ment. Their surface may be smooth or nodulated. They may start in a neigh- 
boring cavity and involve the orbit secondarily. 
Their etiology is very obscure. 
Symptoms and Course.—They grow very slowly, are never sensi- 
tive to pressure, and when they cause pain it is either from pressure on 
some sensory nerve or from some localized inflammation. There is 
exophthalmos, more or less limitation of motility of the eye, sometimes 
ulceration of the cornea and disturbance of vision, with diplopia. 
Ophthalmoscopically, there may be noticed all the changes in the retina 
and optic nerve from hvperaemia, through papillitis, to atrophy of the 
optic disk. If the cavity of the skull be encroached upon, grave 
cerebral symptoms will result. They are extrendy hard and immobile. 
A careful examination must be made of the condition of the various 
neighboring cavities, for such a tumor may be mistaken for a distention 
of the ethmoid cells or frontal sinus. 
If confined to the orbital wall, the prognosis is favorable. 
Treatment.—The treatment of pure osteoma or ivory exostosis con- 
sists in its operative removal. This is very tedious, somewhat difficult, 
and, if the roof of the orbit be involved, the danger to life is by no means 
slight, statistics showing a mortality of 38 per cent. The periosteum 
must first be incised and carefully stripped off from the tumor and for 
some distance from its base. Then a narrow groove should be cut with 
a chisel or gouge and mallet around the base, the blows with the mallet 
being made gently and rapidly until the tumor becomes loosened. Then 
a gentle rocking motion to and fro will usually suffice to detach it. If 
the bone be found very dense, small holes may be drilled in it by means 
of a dental engine, and the operation subsequently completed by a chisel 
and mallet. These tumors show no tendency to recur. 
Tumors of the Optic Nerve. 
Tumors of the optic nerve, originating in the nerve-fibres or sheath of 
the nerve, are rare. They may involve any portion of the nerve be- 
tween the eyeball and the optic chiasm, but in by far the greater number 
of cases the orbital part of the nerve is the seat of the growth. 
These tumors vary in size from that of a hazelnut to that of a large egg. 
Sometimes the nerve passes through the centre of the tumor and is spread out in 
it, and more rarely it is found on one side of the growth. The tumor grows either 
from the dural sheath, or from the pial sheath, or from the stem of the nerve. 
Tumors met with in this locality may be epitheliomata or endotheliomata, sarco- 
mata, gliomata, myxo-sarcomata, fibro-sarcomata, and neuromata. In all these 
varieties cystoid degeneration is frequently met with. Most of the cases reported 
have occurred in young persons before the age of puberty. The endotheliomata 
usually grow from the dural sheath, the sarcomata from the pial sheath, and the 
neuromata from the neuroglia of the nerve. In all cases the optic nerve is more 
or less flattened and atrophied. 
Symptoms.—These vary with the size, shape, and location of the 
growth. Optic neuritis, or papillitis and atrophy of the optic nerve, 
with resulting loss of vision, are early symptoms. The progress is slow 
and usually painless. The protrusion of the eyeball is generally straight AFFECTIONS OF THE EXTERNAL MUSCLES OF THE EYES. 
747 
forward in the direction of the axis of the eye, and, unless the tumor be 
large, the motility of the eyeball is not much interfered with, though 
diplopia may be present from the beginning. In rare instances the 
growth may be so rapid as to interfere with the nutrition of the globe, 
and ends in perforation of the cornea and atrophy of the eye. 
It is rarely possible to diagnosticate correctly a true tumpr of the optic nerve, 
as most of the symptoms are common also to cases of orbital tumors which may 
have involved the optic nerve secondarily. 
Treatment.—This consists in removal of the growth by operation. 
An attempt should always be made to remove the tumor without enu- 
cleating the eyeball, and this has been successfully done in a number of 
cases. If, however, the tumor be of large size or have involved the orbital 
tissue extensively, the entire contents of the orbit, including the eye, 
must be removed. Recurrence of the growth in the latter case occurs 
but rarely. 
Strabismus, or Squint.—The subject of strabismus can receive but 
very brief mention in a work on General Surgery, as its intimate con- 
nection with errors of refraction, with congenital amblyopia and arrest 
of development of the retina or optic nerve, or both, and with possible 
undeveloped conditions of the nuclei of origin of the motor nerves, or 
with abnormally increased nervous inhibition, make it the most obscure 
and complicated chapter in ophthalmology. 
Strabismus, or squint, is that condition of the eyes in which the 
visual axes of the two eyes, when prolonged, do not meet in the object 
of fixation. If these prolonged axes meet before reaching the object of 
fixation, the condition is termed convergent strabismus. If these axes 
when prolonged never meet, but diverge from each other, the condition 
is known as divergent squint. Either of these conditions may exist alone 
or may be accompanied by loss of power or paralysis of the antagonistic 
muscles of one or both eyes. In the former case the deviation is termed 
primary squint; in the latter it is known as secondary or paralytic 
squint. Primary squint is almost always associated with some error of 
refraction, usually hypermetropia, and generally with marked impair- 
ment of vision of the squinting eye. In the comparatively rare cases in 
which the deviation exists in both eyes there is commonly a difference 
in the degree of refractive error and in the acuity of vision of the two 
eyes. 
A convergent squint may exist at times in one eye, and at times in 
the other, and is then called alternating. It may at times exist and at 
times be absent, and it is then called periodic. In primary squint there 
is almost never any diplopia. In secondary or paralytic squint, if the 
vision of both eyes be good, diplopia is almost always present. 
Affections of the External Muscles of the Eyes. 
Primary squint is almost always an affection of early childhood. Secondary or 
paralytic squint may occur at any period of life. 
Etiology.—The causes of primary squint are very obscure, and are 
intimately associated with errors of refraction, increased nervous inhibi- 
tion, and certain conditions of general nerve-supply as yet but little 748 
INJURIES AND DISEASES OF TIIE EYE AND ORBIT. 
understood. Secondary or paralytic squint is due either to some local 
focus of disease in the orbit or brain, to some general blood disorder like 
syphilis, or to traumatism. 
Treatment.—In the case of primary convergent squint the treat- 
ment is partly optical by means of properly fitted lenses, and partly 
surgical, and should be undertaken solely by the ophthalmic surgeon. 
In the case of secondary or paralytic squint the treatment should be 
directed, first of all, to the constitutional cause of the affection, and sub- 
sequently such surgical operations should be undertaken as may be 
indicated to restore the disturbed motility of the eyeball. 
Paralysis of the External Ocular Muscles.—Paralysis of the ocular 
muscles may be due to some general blood disorder, such as syphilis or 
rheumatism ; to foci of disease in the brain; or to traumatism, whether 
accidental or surgical. Any single muscle may be paralyzed or all the 
external muscles of the eye may be involved in the same process. 
The external rectus muscle, supplied by the sixth nerve, is much more fre- 
quently paralyzed than any other ocular muscle, and the paralysis may be tempo- 
rary or permanent. The symptoms are an absolute immobility of the eye outward, 
a secondary convergent squint, and double vision. 
Next in order of frequency is a paralysis of the muscles supplied by the third 
nerve, any one of which or all of which may be affected. These symptoms are 
diplopia; divergent squint or upward squint or downward squint; ptosis; immo- 
bility of the eye inward, downward, or upward; dilatation and immobility of the 
iris; and loss of the power of accommodation. The two latter symptoms point to 
paralysis of the branches of the third nerve going to the iris and ciliary muscle. 
The position of the double images with reference to each other varies with the 
muscle or muscles paralyzed, and is of too complicated a nature to be entered 
on here. 
When all the branches of the third nerve are involved the condition 
is known as ophthalmoplegia externa and interna. 
Paralysis of the superior oblique or trochlearis muscle is due to a 
lesion of the fourth nerve or its nucleus of origin. It is a rare occur- 
rence, and the objective symptoms are so slight that the paralysis cannot 
be determined except by close examination of the behavior of the double 
images. 
Treatment.—The treatment of all these muscular paralyses should 
be directed toward obviating the cause, and is generally medical in 
character. 
Nystagmus.—This is a term applied to involuntary oscillatory or 
rotary motions of the eyeballs due to rapid alternate contractions of 
one pair of straight muscles, or to similar action on the part of the 
oblique muscles, or to both combined. It may be either congenital or 
acquired. The former is accompanied either by cataract or by imper- 
fect development of the retina or optic nerve. The acquired form may 
be due either to corneal opacities or to fatigue of the nerve-centres of 
the eye by working in a strained position, as in miners. It is also a 
symptom of disseminate sclerosis of the brain and spinal cord. 
Treatment is of no avail. CHAPTER XIX 
SURGICAL INJURIES AND DISEASES OF THE EAR 
Clarence J. Blake, M. D 
The surgery of the ear may be divided, operatively speaking, into 
General and Special, the former including such operations as come with- 
in the province of the general surgeon, and the other those requiring the 
manipulation of minute instruments directed by sense of touch in a field 
illuminated by reflected light, approached through a small opening, and 
confined to a cavity which presents a great variety of structures and 
intimately related contiguously to important parts, the invasion of which 
would be a matter of serious consequence. Indeed, the surgery of the 
temporal bone requires to an unusual degree a knowledge of minute 
anatomy and a tactile appreciation of locations and distances. 
The first class of diseases and their operative relief would, under this division, 
include the treatment of the malformations, injuries, and diseases of the external 
ear, of the outer portion of the external auditory canal, and of the superficies of 
the mastoid process, while the second class would include the special operations 
upon the membrana tympani, within the tympanic cavity, and in the depths of 
the mastoid. 
The congenital deviations of the auricle from the normal type 
include malpositions of the auricle as a whole; deformities of certain 
portions of the auricle, the remainder being normal; anomalous shape 
of the auricle, resulting either from injury or from arrest of development 
during intra-uterine life; and, finally, the presence of either supernu- 
merary auricles or of supernumerary portions of the auricle. 
The malformations most commonly demanding surgical treatment 
are those in which there is a marked arrest of development accompanied 
by impairment of hearing, those in which supernumerary portions are 
to be removed, and those in which the auricle, in other respects normal 
in position and structure, projects unduly from the side of the head. 
In very young children the projecting auricle may, since the cartilage of which 
this structure is formed is at an early age soft and pliable, be successfully treated by 
fastening the auricle back against the side of the head, either by painting the pos- 
terior portion of the concha and the adjacent portion of the mastoid region with 
collodion, bringing the two surfaces in contact, and applying a light gauze bandage, 
or by applying the bandage alone, or a cap which may be continuously worn : in 
the adult this simple treatment is less efficacious, because of the greater elasticity 
and firmness of the cartilage, but that it may occasionally be effectual is shown by 
the result of the pressure of the head-band worn by some orders of religious sister- 
hoods. 
When the auricle is very prominent and the cartilage thick and firm, 
it is usually necessary to effect an attachment between the posterior por- 
tion of the concha and the surface of the mastoid region. This is best 
749 750 
SURGICAL INJURIES AND DISEASES OF THE EAR. 
done by removing an elliptical portion of skin, including a part of the 
posterior surface of the auricle and of the mastoid, in one denudation, 
the edges of the cut upon the auricle and mastoid being brought into 
apposition and secured by stitches : a light but firm bandage is then car- 
ried over the auricle and around the head, and, except for renewal, 
should not be removed until the healing of the wound is complete, 
Where the cartilage of the auricle is thick and unyielding, it may be 
thinned either by means of the curette or knife, care being taken that 
this is done evenly; otherwise when the auricle is pressed backward, a 
break may occur in the cartilage at the thinnest point, with the resulting 
deformity of a projection upon the anterior surface of the auricle. 
As a preliminary to this operation, in addition to the usual cleansing of the 
skin and other aseptic precautions, the auricle should be pressed backward into 
the position in which it is desired to fasten it, and a mark made upon the concha 
and mastoid to indicate the limit and contour of the incision to be made. 
The commonest form of complete microtia is that in which the tuber- 
cles of cartilage which subsequently form the helix, antihelix, and the 
tragi are still distinct, and, since it is the result of an arrest of develop- 
ment at an early period of intra-uterine life, it is not uncommonly 
accompanied by an arrest of development of the corresponding side of 
the face, of the external auditory canal, and sometimes of the sound- 
transmitting structures of the middle ear. 
The rudimentary auricle itself contains so little basal cartilage, and is in the 
majority of these cases so merely an involuted reduplication of skin, that it 
affords very little material for a plastic operation, and, so far as appearances are 
concerned, is better left untouched, entirely removed, or replaced by an artificial 
representation of a normal ear; while the incompleteness of the deeper portions 
of the organ of hearing of which this form of microtia is significant, give in the 
majority of cases but little hope of an improvement in the hearing by operative 
interference. 
The supernumerary portions of the auricle most commonly found are 
small nodules of cartilage or of connective tissue, covered with skin, in 
front of the ear, which may itself be quite normal in shape, size, and 
location. These projections are easily removed by excision, a small flap 
of skin being taken from one side and stitched or otherwise secured in 
the space left by the removal. 
Incised and contused wounds of the auricle are likely to result in a 
considerable degree of deformity, either from imperfect coaptation of the 
edges of the wound or from subsequent perichondritis or necrosis of the 
cartilage, unless they are treated shortly after injury and with especial 
reference to the peculiar structure of the auricle. This is a thin plate of 
unsupported cartilage covered with integument, and subjected, in the 
event of a solution of its continuity, to the action of small muscles, 
which, though rudimentary and weak, become effective in their action 
when the continued resistance of the cartilage to which they are attached 
is removed. 
Where operation is requested for the relief of such deformity resulting 
from injury, as the incurving of the pinna from above forward, this may 
be effected by subcutaneous dissection of the integument on the anterior 
surface of the auricle, and by an operation on the posterior surface com- 
parable on a small scale to that made use of for tying back the auricle as 
a whole. OTIIJEMA TOMA. 
751 
As a result of blows upon the auricle there is not infrequently a severe 
contusion or fracture of the cartilage, with extravasation of blood under- 
neath the integument and perichondrium : this occurs usually on the 
anterior surface of the auricle and in its upper portion, and is similar in 
appearance and location to the extravasations which have been found to 
occur, without history of injury, in the insane, and have been produced 
artificially in dogs by section of the restiform bodies, except that the 
traumatic othcematoma is usually larger, more tense, and accompanied 
by pain. 
In the traumatic othsematoma the extravasation of blood which peels 
up the perichondrium and skin is usually the result of a fracture of the 
cartilage, while in the idiopathic form there is sometimes a disease of 
the cartilage as the basis of the hemorrhage or effusion. 
The othcematoma usually presents itself as a smooth rounded swelling, 
filling the upper anterior portion of the auricle above the concha, and 
obliterating the normal elevations of the helix, antihelix, and their cor- 
responding fossae; it occurs either immediately after an injury, when it 
is accompanied by sensations of pain and tension, or idiopathically, with- 
out pain or other disturbance, sometimes during sleep, the patient awak- 
ing with a sense of fulness in the auricle as the first evidence of an 
abnormal condition. 
The treatment of the recent othaematoma should be directed, first, to 
the evacuation of the contents of the sac, and, secondly, to the prevention 
of deformity, which is likely to occur from the contraction of remaining 
blood-clots, the puckering of the skin, and the consequent malposition 
of the fractured or weakened cartilage. 
Evacuation by aspiration, while immediately effectual in removing 
the serum, is apt to leave a remaining blood-clot and give, moreover, 
only temporary benefit, since the sac speedily refills; a free incision 
should, therefore, with due aseptic precautions, be made in the most de- 
pendent portion of the tumor and the fluid contents evacuated, not only 
by gentle pressure from above downward, but by passing a cotton-tipped 
probe, properly sterilized, into the sac and carefully wiping out any 
remaining blood-clots or small pieces of cartilage, which, both in the 
traumatic and idiopathic cases, are sometimes found to have separated. 
If the otluematoma is of long standing and the cotton-tipped probe be 
not sufficient to cleanse the sac-walls, the sharp spoon should be used 
and the walls effectually curetted. After evacuation of the sac complete 
apposition of the walls should be effected by applying to the anterior 
surface of the auricle, over the evacuated sac, small pads of sea-sponge 
cut to fit into place, wrung out in boiled water, partially dried, and kept 
in place by a narrow flannel bandage passing over the auricle and around 
the head, the auricle being supported posteriorly by gauze sponges. At 
the end of twenty-four hours the bandage and pads should be removed, 
care being taken, if there be evidence of adhesions between the sac-walls, 
to hold the auricle between the thumb and finger after the pressure of 
the bandage is removed. 
If the sac refill, the evacuation and bandaging should be re- 
peated ; more than three or four daily dressings are seldom required to 
bring about adhesion of the walls of the sac, and when this has been 
effected the auricle should be massaged by a gentle rubbing or rolling 752 
SURGICAL INJURIES AND DISEASES OF THE EAR. 
of the affected part between the thumb and finger for five or ten minutes 
three or four times daily. 
The auricle is frequently the seat of small warty growths occurring 
usually on the Avails of the concha, of small cysts, and occasionally of 
gouty deposits, all of which may be treated according to the simple rules 
applicable to the removal of such abnormalities elsewhere. 
The lobule is occasionally the seat of fibrous tumors, rarely attaining 
any considerable size or occurring frequently except in the negro race. 
When these tumors are large it is sometimes necessary to sacrifice the 
whole lobule, the tumors being removed by careful dissection, leaving a 
small flap of skin to be turned under the lower edge of the cartilage of 
the auricle to form a small lobnle ; tumors of moderate size may be in- 
cluded between two cuts of the scissors, making a triangle, the apex of 
which should be below the cartilage, the space between the two lines 
including the tumor and such portion of the lobule as it may be neces- 
sary to remove in order to get good opposing edges: care should be 
taken not to carry the cut upward into the cartilage, as the small artery 
running along its inferior border is likely to cause troublesome bleeding, 
interfering with the subsequent healing of the cut edges, which should 
be brought into apposition and secured by means of collodion dressing 
and without sutures, experience having shown that the suture points are 
liable to become centres for new fibroid growths. 
Epithelioma of the auricle is of infrequent occurrence, a review of 
14,747 cases of all diseases of the ear showing that it occurred but twice. 
Relief is most commonly sought on account of the severe pain which 
accompanies the development of the nodular projection upon the ante- 
rior surface of the auricle, the primal appearance of a carcinomatous 
growth being rare on the posterior surface. 
When a large portion of the auricle has been attacked, its entire removal, with 
that of a part of the whole of the cartilaginous canal, is indicated, and this should 
be done in the following manner: The skin should be carefully examined to deter- 
mine the location of any nodular points, all of which in the immediate neighbor- 
hood of the auricle should be included in the field of operation, and the incision 
should be made beyond the indurated surface and in the sound tissues only. 
Beginning at a point above and behind the auricle, the fh'st incision should be 
made as close to the point of auricular attachment as the condition of the skin 
will permit, and the dissection carried backward and downward in a curve to a 
point below the lobule: from this incision the skin should be dissected up,and the 
dissection carried along the curve of the mastoid into the auditory canal, thus 
separating the posterior auricular attachments and carrying the auricle with its 
collar of skin forward, traction on the auricle forward, upward, and downward, as 
the cutting proceeds, permitting a ready division of the muscular and ligamentous 
attachments above and below. 
The superficial cut is then continued from its beginning forward and down- 
ward outside of the root of the helix, above the tragus, and into the meatus, while 
the end of the cut is continued either through the incisura intertragica, leaving the 
tragus in place, or outside of and including the tragus in case it be necessary also 
to remove that portion of the cartilage. • 
The removal of the auricle in cases of epithelioma sometimes implies 
the creation of a surface of greater or less extent to be covered by granu- 
lation-tissue, and the utilization of any skin-flaps which may be obtain- 
able without danger of a recurrence of the growth should of course be 
considered. Where the upper portion of the auricle only is implicated 
and the lobule may be left, it can be utilized for covering; the lobule, FOREIGN BODIES. 
753 
which is merely a reduplication of skin, vascular and well nourished, and 
with a small artery passing into it from a point on its anterior border, 
may be separated in removing the cartilaginous portion of the auricle, 
left hanging by its anterior attachment, and, after removal of the auricle 
be used by splitting and spreading to cover a considerable denuded sur- 
face. Where it has been necessary also to denude a large portion of the 
mastoid surface a long incision may be made in the scalp posteriorly to 
the mastoid, the subcutaneous tissue dissected up, and the scalp slipped 
forward to cover as large a portion of the mastoid as is possible by this 
means, the scalp opening being allowed to close by granulation-tissue; 
the aural wound should be dressed antiseptically, a gauze tampon being 
placed in the external auditory canal, and when granulations appear over 
the surfaces which it has not been possible to cover with skin, dermatiza- 
tion may be effected by first drying the granulation surface and then 
carefully covering it with a strip or strips of bond or so-called parch- 
ment paper, which is kept in place under pressure by means of sterile 
dressings and firm bandages. At the end of the third or fourth day the 
paper is usually either firmly adherent or comes away, leaving beneath 
it flattened granulations covered with a fine pavement epithelium. In 
using this form of automatic grafting the paper dressing should, if pos- 
sible, be applied in one piece and carried over on to the sound skin, new 
skin-growth being found, under these conditions, to project itself in con- 
centrating lines from the sound edges toward the centre of the granulat- 
ing surface. 
Injury of the External Canal. 
Among the injuries to the external auditory canal of extrinsic origin 
should be mentioned fracture of the anterior inferior wall of the bony 
canal, forming the posterior wall of the glenoid fossa, as a result of 
blows upon the lower jaw, the bony plate in some cases being not only 
fractured, but turned up edgewise through the skin into the lumen of 
the canal. 
Foreign Bodies. 
The foreign bodies which find their way into the ear, and for the 
removal of which interference is required, are of two classes—the ani- 
mate and inanimate, the former including various insects and their larvae, 
and the latter almost any substance small enough to be introduced into 
the external auditory canal. 
The presence of an animate body is usually evident to the patient by 
sensations of movement within the ear, and of pain accompanied by 
noises incident to the movement of the living creature. The speediest 
relief from these symptoms is afforded by turning the affected ear up- 
ward and filling it with either warm water or warm oil for the purpose 
of drowning the insect, which may afterward be removed by means of 
the forceps under a good illumination, or by simple syringing. 
The larvae of the house-fly and blow-fly are sometimes found in the ear in cases 
of suppurative disease: their presence may usually be determined objectively as a 
whitish moving mass in the depth of the ear, and an occasional indication of their 
presence is the streaking of the purulent discharge with blood flowing from the 
mucous membrane, wounded by the hooks with which the larvae attach themselves, 754 
SURGICAL INJURIES AND DISEASES OF THE EAR. 
the subjective symptoms being a sharp stinging pain in the ear accompanied by a 
sensation of movement. An attempt at removal of the larvae by means of the for- 
ceps not uncommonly results in their being torn to pieces, traction upon their 
bodies drawing the hooks downward and fixing them more firmly in the skin or 
mucous membrane. As their breathing apparatus is at the ventral end, they may 
be made to loosen their hold by filling the ear with warm oil or glycerin. 
The inanimate bodies most commonly found in the ears of children 
are beans, peas, pieces of slate-pencil, beads, boot-buttons, small shells, 
and pebbles. Where the foreign body is situated in the outer half of 
the canal it may sometimes be easily removed by turning the affected ear 
downward, seizing the auricle between the finger and thumb, and rotat- 
ing it forward and backward, this movement serving to make the wall 
of the cartilaginous part of the canal impinge upon one side and then 
the other of the foreign body and loosen it from its place. If the foreign 
body have been pushed beyond the narrow portion of the canal and is 
lodged near to or in contact with the drumhead, its removal should be 
attempted, otherwise than by syringing, only under a good illumination 
and with great care, it having not infrequently happened that injudicious 
attempts at removal of a hard foreign body by means of forceps and 
other instruments have resulted not only in wounding the lining of the 
canal, but in rupturing the membrana tympani and forcing the foreign 
body into the tympanic cavity. 
When the foreign body is so firmly imbedded at the inner end of the canal or 
in the middle ear as to make its extraction by the natural channel impossible, it 
may be necessary to reflect the auricle and cartilaginous portion of the canal, or 
even its entire lining, forward. This should be done under ether and with the 
usual aseptic precautions, an incision being made behind the auricle close to its 
attachment, and the dissection along the posterior wall of the canal being carried 
to the point of attachment of the cartilaginous to the osseous portion, which may 
then be separated, exposing the inner end of the canal, with its soft tissues intact, 
freely to view; or, without dividing the canal, the soft parts may be entirely dis- 
sected away from the bone as far as the emulus tympanicus, the soft tissue at this 
point being divided by the angular knife introduced through the canal or by 
further dissection from behind forward: should the foreign body be so large, of 
such material, or so firmly imbedded in the middle ear as to make its piecemeal 
extraction necessary, the first incision should be made not merely behind the 
auricle, but should begin above it, in order that a larger operative field may be 
obtained and that room be secured, if necessary, for cutting away portions of the 
bone. 
After removal of the foreign body the ear should be thoroughly cleansed with 
an antiseptic solution, the soft parts replaced, and the outer wound closed by 
stitches. 
The External Auditory Canal. 
The commonest form of acute infectious process of the external audi- 
tory canal is furuncle, or boil, which is found principally in the outer 
portion of the canal, and rarely in the concha or upon the auricle. These 
boils of parasitic origin occur singly, more commonly successively in 
groups, and have all the characteristics of the same form of inflammatory 
process elsewhere, but are liable to be especially painful because of the 
circumscribed region in which they occur, the thinness of the skin, and 
the resisting character of the underlying tissues. 
In addition to the pain, which is at first dull and continuous and later 
of a lancinating character, there is a sensation of heat and fulness in the 
ear. In the earlier stages, when the skin is red and tumefied, the exact THE EXTERNAL AUDITORY CANAL. 
755 
location of the inflamed gland may be determined by tactile inspection 
with a bent probe, pressure on the skin immediately overlying the point 
of inflammation being indicated by a slight sharp pain. Gentle pressure 
with the probe marks the spot by a momentary depression in the oedem- 
atous skin, and a deep incision with a small curved bistoury usually 
brings the desired relief. 
In the limited necrosis of the bony canal which accompanies an ulcerative 
process of the soft tissues, following either circumscribed or diffuse inflammation, 
the more common locations of the lesions are the rough lip of bone which forms 
the inferior outer termination of the osseous auditory canal and serves for the at- 
tachment for the cartilaginous portion, and the thin bone on the posterior wall of 
the canal. 
The symptoms which bring patients under observation in these cases 
are either the discomfort incident to a flow of pos from the ear or an im- 
pairment of hearing, accompanied by a sense of fulness or other indication 
of the presence of a foreign body in the canal, and which is found on 
inspection to be due to an accumulation of epidermis. On further exam- 
ination it is evident that both the pus and exfoliated epidermis have their 
origin in granulations which overlie a small surface of necrotic bone. 
The occurrence of a large furuncle at the junction of the cartilaginous 
and osseous portions of the canal, followed by subsequent ulcerative de- 
struction of the thin upper dermoid wall, will sometimes leave a cavity 
of considerable depth either tilled with granulation-tissue or with masses 
of exfoliated epidermis, the removal of which by means of the forceps 
or by syringing reveals the true condition of affairs, the depression in 
the wall of the canal being found to have somewhere upon its surface 
redundant granulations, at the bottom of which, by means of a probe, a 
spot of carious bone may be felt. In the majority of these cases relief is 
obtained by the simple process of thorough and sometimes repeated 
curetting through the external canal, but it is occasionally necessary 
where the necrotic portion is more extensive to reflect the auricle for- 
ward in search of a sequestrum or for the purpose of removing the dis- 
eased bone by means of the chisel. 
Exostoses of the external auditory canal, like the hyperostoses, are 
usually the result of a circumscribed periostitis, such as may occur in the 
course of a chronic suppuration of the middle ear, though their occur- 
rence as multiple growths in succeeding generations favors the imputa- 
tion of an hereditary tendency. 
The hyperostoses rarely require operative interference, but the exostoses 
of large size which have their origin on the anterior superior or posterior 
inferior lip of the osseous meatus, as well as the rounded exostoses which 
occur singly or in groups deeper in the canal, sometimes project so freely 
into its lumen as to make their removal a necessity. 
A careful examination of the contour and location of an exostosis is 
an important preliminary to its removal, and this may be done with a 
bent probe passed beyond the growth or by means of the loop of a wire 
snare slipped over it. 
The removal of exostoses is best effected by means of a fine dental 
drill making successive openings through the base of the growth, which 
is then broken away by means of the burr worked by a dental engine. 
Another form of obstruction of the external auditory canal, but one 756 
SURGICAL INJURIES AND DISEASES OF THE EAR. 
involving the soft tissues only, is that which follows the granulomata 
occurring in the canal as the result of an ulcerative process incident to 
suppurative middle-ear disease or otherwise, and consists usually in an 
annular constriction or narrowing of the canal by secondary granulation- 
tissue. Dilatation of the constriction by sea-tangle tents, either with 
or without previous multiple incision, is frequently of doubtful result, 
and in some of these eases the following procedure has proved of service, 
its object being to remove the redundant tissue and at the same time to 
preserve the continuity of the dermoid lining of the canal. 
With a sharp curved bistoury, passed beyond the point of constriction, a 
triangular incision is made on the wall of the canal, with the base of the flap thus 
formed outward. By means of a sharp curette the apex of the skin-flap is lifted 
and gradually dissected outward to the base, turned outward, scraped clean of all 
redundant tissue, and replaced ; after a thorough curetting of that portion of the 
constriction which lay beneath it, the canal is then cleansed antiseptically and the 
flap kept in position by a tampon until union has taken place. 
The Membrana Tympani and the Tympanum. 
The membrana tympani, while exceedingly firm and resistant, is 
comparatively inelastic: it may therefore be ruptured throughout by 
such application of general force to its whole surface as would accom- 
pany the sudden condensation of air in the external canal or middle ear; 
it may be torn across as an effect of contre-coup in consequence of a 
blow on the opposite side of the head ; or it may be wounded by the im- 
pact of some foreign body introduced through the external canal. In 
the first and second instances there is usually a solution of continuity of 
all the coats of the drumhead, the laceration extending from one periph- 
ery to the other, and commonly parallel with and close to the long 
process of the malleus, while in the latter case the injury is usually 
limited to a small area around the point impinged upon ; in both classes 
of cases the rent is an irregular one, and, as the mucous coat of the 
drumhead is exceedingly vascular, the injury is likely to be accompanied 
by hemorrhage into the tympanic cavity. If the rupture of the drum- 
head be an extensive one, with bleeding into the tympanum, and the injury 
be recent, the middle ear should be gently inflated by means of the 
Politzer air-douche or catheter, and the meatus carefully cleansed, a dry 
cotton-tipped probe being used in preference to the syringe : if syringing 
is rendered necessary by the presence of an extraneous substance or of 
cerumen or epidermis in the canal, this should be done only with steril- 
ized water or an antiseptic solution : after cleansing, the ruptured edges 
of the membrana tympani, if not already in contact, should be placed so 
by gentle manipulation with a cotton-tipped probe from without and by 
inflation of the middle ear from within, it being borne in mind that the 
less the parts are handled the better; but the apposed edges of the cut 
may be covered by a paper dressing previously dipped in sterilized 
water or a weak corrosive-sublimate solution. 
A blood-dot in the healthy tympanic cavity is a matter of little moment, 
except in so far as temporary interference with sound transmission 
is concerned, and the structure of the drumhead is such—there being a 
fibrous coat in two layers, the outer of which is made up of radiating 
and the inner of circular fibres placed between an outer dermoid 757 
THE MEMBRANA TYMPANI AND THE TYMPANUM. 
and an inner mucous coat—that when wounded or ruptured the edges 
of the cut or wound tend to return to a normal position and come 
together. The ear should finally be closed with cotton and the patient 
directed to avoid blowing the nose for at least forty-eight hours. 
In those cases of chronic, non-suppurative middle-ear disease 
where operation is undertaken with a view to possible improvement of 
the hearing, and in other cases of the same class where the exact deter- 
mination of the character and location in the sound-transmitting appa- 
ratus of the obstacles to the passage of the sound-waves is a matter of 
difficulty, the question of some method of exploratory operation which 
shall take advantage of the intelligent participation of the patient is a 
matter of importance. 
Tactile investigations as to the comparative sensitiveness of different portions 
of the tympanic cavity show its lining membrane and intrinsic structures, Avith the 
exception of the superior and posterior portion—fornix tympani and aditus ad 
antrum mastoideum—to be comparatively insensitive. 
Operations within the middle ear, therefore, except such as include 
interference with the membrana tympani and invasion of the upper por- 
tion of the tympanic cavity, may, in the great majority of cases, witli 
proper care, be conducted not only without general, but also without 
local, anaesthesia; and in the cases, therefore, of chronic non-suppurative 
disease of the middle ear with intact membrana tympani, for which this 
operation of exploratory tympanotomy is proposed, when the sensitive 
membrana tympani has once been passed there is opened to the observer 
an aseptic and comparatively insensitive cavity. 
The operation should be preceded by that thorough cleansing of the 
external auditory canal and of the instruments which are appropriate to 
the opening of an aseptic cavity, while the same precautions should be 
observed throughout the operation. 
The only instrument needed for the opening of the tympanum through the 
membrana tympani is a paracentesis needle, but, as the exploratory operation may 
include mechanical tests for the mobility of the ossicles and may lead to the per- 
formance of plicotomy, syncechtomy, tenotomy of the tensor tympani or of the stapedius 
muscle, circumcision of the stapes in the fenestral niche, or even, in extreme cases, 
the attempt at the removal of that bone, the following instruments should be pro- 
vided : Two angular knives, one right angle and one at an angle of forty-five 
degrees for plicotomy, tenotomy, and the division of articulations; two blunt 
hooks, one large, for testing the mobility of the larger ossicles, and the other for 
manipulation of the stapes; a small paracentesis needle for tenotomy of the sta- 
pedius and for operation in the stapedial niche; two pairs of fine angular forceps, 
one straight and the other curved upward slightly at the tip. 
In addition to these instruments and a number of sterilized cotton-tipped 
probes, there should be a saturated solution of boracic acid and alcohol and a 
1 per cent, sterilized solution of cocaine; the former for dipping the instruments 
before using, and the latter for the purpose of local anaesthesia and to temporarily 
■check congestion and hemorrhage. 
The details of the operation are as follows : The patient is seated 
in a chair, the head being firmly supported by an assistant, who alters its 
position from time to time according to the directions of the operator. 
Under good illumination the first incision is made with the paracen- 
tesis knife close to the periphery of the membrana tympani, opposite the 
round window, and carried upward along the periphery, with or without 
successive applications of cocaine solution on a cotton-tipped probe to 758 
SURGICAL INJURIES ANI) DISEASES OF THE EAR. 
the cut edges as the sensitiveness of the patient may demand : this first 
portion of the cut ends at a point close to the short process of the mal- 
leus, and is thence carried downward along the posterior border of the 
long process of the malleus. 
The resultant flap usually curves outward and downward, and per- 
mits free access to the parts beneath : when this does not occur the flap 
may be pulled gently outward by means of the blunt hook. 
Through the opening thus afforded it is possible to test the mobility of the 
ossicles, to make tactile examination of the parts beyond sight, and to perform 
such operations as the tests of hearing and the tactile examinations may indicate, 
including, for example, divisions of folds and adhesions, mobilization of the ossi- 
cles, tenotomy of the stapedius and tensor tympani muscles, circumcision of the 
stapes, and division of the incudo-stapedial joint, without local anaesthesia, except 
in so far as the membrana tympani is concerned, the absence of general anaesthesia 
permitting tests of hearing at progressive stages. 
At the conclusion of the examination or operations within the tym- 
panum, as the case may be, the flap in the membrana tympani is replaced 
by applying to its outer surface a disk of thin glossy writing-paper pre- 
viously dipped in a weak corrosive solution : this disk is introduced on 
a moist cotton-tipped probe, kept in contact with the flap for a few 
seconds until it adheres to it, and then, carrying the flap with it, is 
pressed upward until the paper also adheres to the drumhead above the 
cut, thus sealing the wound and keeping its edges in apposition. 
If aseptic precautions have been properly taken, the wound in the 
drumhead closed in this manner usually heals by first intention. 
Operation for the removal of the membrana tympani, malleus, and 
incus for the purpose of improving the hearing in cases of non-suppura- 
tive diseases of the middle ear, as originally proposed by Kessel, is very 
similar to the operation for the removal of the malleus and incus in cases 
of suppurative disease, and should be done with the most careful atten- 
tion to asepsis. 
This operation, undertaken for the improvement of hearing, is of 
little benefit unless it take into consideration also the release of the 
stapes and its possible utilization as the point of contact for some form 
of artificial drumhead. 
In acute inflammation of the middle ear incision of the mem- 
brana tympani may be required either for purposes of phlebotomy or 
for the release of secretions retained within the middle ear. 
In cases of acute congestion occurring in the upper portion of the 
tympanum, and characterized subjectively by intense pain and objec- 
tively by congestion and swelling of the upper, more vascular portion of 
the membrana tympani and the upper portion of the inner end of the 
external auditory canal, prompt action for the relief of the engorged 
tissues sometimes cuts short what otherwise would be the inception of a 
serious and prolonged inflammatory process. The purpose of the incis- 
ion being to divide one of the principal blood-supplies of the membrana 
tympani, the cut should be made along the posterior superior periphery, 
from below upward, and ending at the short process of the malleus. 
After cessation of the temporary hemorrhage the ear should be dressed 
with dry cotton wicks. 
Incision of the membrana tympani for the release of fluid contained 
within the tympanum should be made by the means of the paracentesis THE MEMBRANA TYMPANI AND THE TYMPANUM. 
759 
needle, preferably in the inferior posterior segment, parallel to the periph- 
ery of the drumhead, and should be proportionate in size to the density 
and tenacity of the fluid to be evacuated ; while in view of the sometimes 
considerable swelling of the mucous lining of the tympanic cavity accom- 
panying conditions which render paracentesis necessary, care should be 
taken that the opening is not only sufficiently large to permit the free 
flow of fluid, but also deep enough to effectually penetrate the swollen 
mucous membrane. 
Redundant granulation-tissue and polypi are among the common 
accompaniments of chronic suppurative disease of the middle ear, and 
may spring either from the mucous membrane of the tympanic cavity, 
from the edge of a perforation of the membrana tympani, or, from the 
inner end of the external auditory canal, and vary in structure and size 
according to their point of origin and the space afforded them for growth. 
They may be removed either by touching with astringents or caustics, 
or, operatively, by means of the forceps, the curette, or the wire snare, 
the latter instrument being especially applicable to the larger and firmer 
growths. The stump remaining after successful application of the snare 
should be curetted or treated with caustics until it lias entirely disap- 
peared, it being remembered that a too free use either of the curette or 
escharotics may result in stimulation which will favor redundant tissue- 
growth and even clinical simulation of a malignant growth, or may cause 
inflammation of the surrounding tissues. 
Granulations springing either from the wall of the canal, from the 
mucous membrane of the tympanic cavity, or from the ossicles as the 
result of a circumscribed necrotic process in the bone, may likewise be 
removed by means of a small tubular snare, curved forceps, or the curette, 
and their bases subsequently cauterized. 
Limited necrosis of the inner end of the canal, of the wall of the 
tympanic cavity, or of the ossicles is best dealt with by means of small 
and appropriately shaped curettes, or, in the latter case, if the necrotic 
process is extensive, complete removal of these bones may be necessary. 
By means of a paracentesis needle and an angular knife such portions of the 
membrana tympani as remain should be excised, the tendon of the tensor tympani 
muscle and all adhesions between the malleus and inner tympanic wall divided; 
the anterior and posterior ligaments of the short process of the malleus should 
next be cut, and a spatula-shaped knife carried along the neck of the malleus be- 
tween its head and the outer tympanic wall, and moved backward and forward to 
divide the external ligament of the malleus and any existing adhesions; especial 
care being taken in effecting this division and in freeing the region of the short 
process, it having sometimes happened that with the extraction of the malleus the 
soft tissues have been pulled away from the outer wall of the epitympanic space 
and the superior wall of the external auditory canal. 
When the incus is in place it should be first removed, and if its attachment to 
the stapes remains, this should be divided by means of an angular or rectangular 
knife, the cutting motion in dividing the joint being from behind forward, in order 
to make traction against, rather than with, the pull of the stapedius muscle: the 
complete division of this joint is usually signalized by the dropping downward and 
outward of the long process of the incus, the preponderating weight of that bone 
above its axial line of movement tending to carry the body of the bone inward and 
its descending process outward. Under these conditions the long process of the 
incus may be seized by the curved forceps and the bone extracted by a direct pull 
downward and outward. Where this is not possible, however, and the incus re- 
mains above the line of sight, or, separated from its articulation with the malleus, 
is drawn upward and backward by the pull of its posterior fan-shaped ligament, it 760 
SURGICAL INJURIES A$D DISEASES OF THE EAR. 
should be carefully searched for with a bent probe and extracted either by means 
of one of the various incus-hooks or a long curved curette. 
The removal of the malleus, released from its various attachments, is effected 
either by means of the forceps already mentioned, or, better still, by encircling the 
neck of the bone above the short process with a tightly drawn loop of a wire 
snare, the bone then being drawn downward and outward with a slight rotating 
motion. 
When, as is sometimes the case, the lower part of the malleus has 
been destroyed by necrosis and only the head or a part of it with the 
neck remains, the location of this remaining portion should be deter- 
mined by tactile examination with a bent probe, and its removal effected 
either by means of a pair of long curved forceps, an incus-hook, or a 
cup-shaped curette. In the event of caries of the head of the stapes the 
carious portion may be removed by means of the forceps or curette. 
After operation the tympanic cavity should be subjected to careful tactile 
examination to detect any points of necrosed bone, which should in their 
turn be curetted; redundant granulation-tissue should be removed, the 
tympanic cavity thoroughly cleansed by syringing with a weak antiseptic 
solution, and the ear stopped with absorbent cotton. 
The subsequent treatment, aside from any further curetting which 
may be necessary, should consist in syringing with a potassium perman- 
ganate or mild astringent solution, touching of granulations, instillation 
of alcohol, and the insufflation of powdered boracic acid, as the condition 
of the individual case may demand. 
In all cases of limited necrosis of the ossicles or of portions of the 
tympanic wall, it is possible that the operative procedure above mentioned 
may be unnecessary, and that the desired improvement may be effected 
by use of the middle-ear syringe and insufflation of powders. Local treat- 
ment of this kind, sufficiently persisted in, has been found efficacious in 
the majority of cases in which the necrosis has not been extensive. 
The Mastoid. 
The mastoid operation may be properly considered to include not 
only the opening of the mastoid cells themselves and the establishment 
of free communication through the mastoid antrum with the middle ear, 
but also the removal of the bony wall forming the boundary between 
the mastoid and the external auditory canal, and of the superior posterior 
bony lamina which forms the outer and lower limit of the epitympanic 
space, with also such diseased portions of the mastoid walls elsewhere as 
may be necessary. 
The initial lesion, of which the establishment of an acute infectious 
process in the cellular structure of the mastoid portion of the temporal 
bone is a complication, may occur as the result of an inflammatory 
process in the soft parts of the external auditory canal, a circumscribed 
periostitis being followed by denudation and death of bone, or, more 
frequently, may be the sequence of an acute congestion or of an acute 
infectious process in the middle ear. In acute congestion of the middle 
ear with an accompanying congestion of the lining membrane of the 
mastoid cells, where the pain, the temperature, and the pulse, the tender- 
ness to pressure in the mastoid region, especially over the mastoid 
antrum, the digastric fossa, and at the mastoid tip, as well as the objec- THE MASTOID. 
761 
five symptoms in the middle ear, indicate the necessity for an opening 
into the mastoid for purposes of local phlebotomy or with a view to 
further interference, the operation should be done only under the most 
Fig. 444. 
Fig. 445. 
Outer surface of mastoid and membrana 
tympani. 
Interior of mastoid and inner surface of 
membrana tympani. 
rigid asepsis, and should be preceded by a free crescentic incision along 
the superior posterior periphery of the drumhead, in case that structure 
is intact. An incision in this location affords not only the freest oppor- 
Fig. 446. 
Vertical section of mastoid process. 
tunity for drainage from the mastoid antrum, but also, as in the opera- 
tion of exploratory tympanotomy, provides a flap which can easily be 
replaced with the least possible interference with the integrity of the 
drumhead and its subsequent value as a vibrating membrane. 
The extent of the operative invasion of the mastoid cavity in the acute 
congestive cases must depend upon the degree to which the bone of the 
mastoid cortex, and the more delicate walls of the mastoid cells, have 
become affected, and may vary from a simple opening of the outer mas- 
toid wall to the establishment of a free communication with the mastoid 
antrum and the middle ear. 
The actual value of a simple incision through the soft tissue over the 
mastoid down to the bone only is that of an extensive superficial mastoid 762 
SURGICAL INJURIES AND DISEASES OF THE EAR. 
phlebotomy, except in those cases of neglected suppurative middle-ear dis- 
ease with mastoid complications, where the pathological process lias sought 
its own relief by perforation of the cortex, and the incision which gives 
vent to the contained pus is but the preliminary to a thorough opening 
and evacuation of the mastoid itself. 
In an uncomplicated case of mastoid operation the preliminary 
incision should be made from above downward, at a distance of about 
a half inch backward from the insertion of the auricle and following its 
curve : the upper portion of the cut should be vertical, and the lower 
portion inclined outward through the soft tissues; small vessels should 
be seized and twisted, and larger vessels ligatured, though this is rarely 
necessary, the use of hot water and the pressure of the retractors being 
usually sufficient to stop hemorrhage from the flaps: this having been 
effected and the bone bared of periosteun, its surface, unless there has 
been spontaneous perforation of the cortex, should be carefully searched 
for evidence of congested or softened bone, such point being chosen for 
the preliminary opening. This, together with the subsequent operation 
within the mastoid, except as regards curetting, may be effectually 
accomplished by means of the chisel or gouge and mallet, though in 
many cases the broad-bladed and long-handled drill worked by hand 
and guided by an educated tactile sense is a convenient and valuable 
substitute. 
The opening in the cortex should be sufficiently large to permit free 
access to the mastoid cavity, and the process of removal of the diseased 
Fig. 447. 
Hammond’s retractor. 
tissue may, in the majority of cases of mastoid disease, be sufficiently 
and effectively accomplished by means of sharp spoons, the process of 
Fig. 448. 
Mastoid curette. 
curetting being accompanied from time to time by careful probing and 
by ocular inspection when possible, the greater part of the operation, 
Fig. 449. 
Mastoid drill. 
however, as a rule, being done by the sense of touch, and requiring 
therefore for its complete performance a tactile knowledge of distances 
and of location of important parts. THE MASTOID. 
763 
In both the earlier stages of mastoid disease and in those cases in 
which the cavity is found to be filled with broken-down cell-walls, granu- 
lomata and pus, but without caries of the antrum or epitympanic space, 
after thorough evacuation the mastoid may be allowed to fill with blood- 
clot, the surface of the wound being flushed with hot water and a simple 
baked dressing applied. 
In cases of long-continued or neglected mastoid disease with spon- 
taneous perforation of the cortex in the digastric fossa or at the tip, the 
pus making its way downward by gravity into the tissues of the neck, 
the preliminary incision should be carried backward over the digastric 
region and continued downward sufficiently to permit free access both to 
the mastoid tip—which wherever carious should be removed—and to the 
upper portion of the course followed by the pus downward, eounter- 
incisions in the neck below being made to afford drainage. 
In cases of prolonged chronic mastoiditis the resultant thickening of 
the cancellated structure furnishes a hard bone, often of considerable 
thickness, through which it is necessary to chisel or drill before reaching 
the objective point in the pneumatic cells of the mastoid or of the mas- 
toid antrum, while in cases of prolonged suppuration with necrosis of 
the antrum or the accumulation of cholesteatomatous masses the sim- 
ple mastoid operation above mentioned may need to be extended to 
removal of the anterior mastoid wall and the outer boundary of the 
upper tympanic space, and the creation of one large permanent opening 
with inverted skin-flaps, or it may be but the preliminary to an opening 
of the cranial cavity in cases of sinus thrombosis or otitic brain-abscess. CHAPTER XX. 
ON SKIAGRAPHY, OR THE APPLICATION OF THE RONTGEN 
RAYS TO SURGERY. 
Roswell Park, M. D. 
Enough time has elapsed since the announcement by Professor 
Rontgen, of Wurzburg, of a new manifestation of energy, which he 
called the “ x rays,” and which others have generally consented to name 
the “Rontgen rays,” to demonstrate their value and their applicability 
for limited but important purposes in surgery. To the method in general 
the name skiagraphy is now generally applied, while the pictures taken 
by the new process are sometimes termed skiagraphs or radiographs. 
While Rontgen is undoubtedly to be credited with the first application of what is 
now known and with the introduction of a suitable method, he, nevertheless, is not 
the first man to recognize that energy proceeds from the cathode in high vacuums. 
Hertz, a brilliant German physicist, endeavored to demonstrate Maxwell’s theory 
that light-waves are identical with electro-magnetic disturbances in ether, which 
ether is the all-pervading elastic medium everywhere regarded as pervading space 
and penetrating all bodies, no matter how solid. Hertz showed that electro-mag- 
netic disturbances in ether were capable, like light, of refraction, reflection, polar- 
ization, dispersion, etc. In 1891 he stated that the cathode rays of a Crookes tube 
were capable of passing through opaque substances in their path inside of the 
tube. Hertz died an untimely death, and his investigations were continued by 
Lenard, who in 1893 announced that these same cathode rays escaped from the 
tube to a certain extent, and that he had obtained photographs through opaque sub- 
stances by their agency. His simple statement, however, attracted no attention. 
Rontgen was following along the lines of Hertz’s and Lenard’s investigations 
when, upon the 8th of November, 1895, while working with a Crookes tube cov- 
ered with a shield of black cardboard, he noticed that a piece of barium platino- 
cyanide paper became phosphorescent. It was this which led him to further 
investigation and the announcement of his “ x rays.” Further tests within the 
ensuing few days showed the penetrative power which they possessed, as well as 
their property of affecting photographic plates as does light; furthermore, that 
they could not, like light-rays, be reflected, concentrated, or diffracted outside the 
tube in which they originate. 
The possibility of provoking the phenomenon of the Rontgen rays appears to 
be inseparably connected with the ultra-gaseous state of matter, which Crookes 
called the radiant or fourth state. All gases are now regarded as composed of 
countless molecules continually moving and jostling each other with incredible 
velocity. When a glass tube containing air is exhausted, the number of these 
molecules is diminished, and each molecule is given a longer free path. If ex- 
haustion be carried to, say, one-millionth of an atmosphere, the minute portion 
of air remaining is exalted to what we may call the radiant state, and here newr 
and strange phenomena may be evoked. A tube thus exhausted, no matter what 
its shape, is known as a Crookes tube, and, as ordinarily constructed, is more or 
less cylindrical or pear-shaped, with a platinum electrode at either extremity. It 
is from the cathode that the x rays proceed, and it appears that from the impact of 
either the ether waves proceeding in a longitudinal direction or of solid particles 
projected from the cathode upon the glass the peculiar energy proceeds. The 
glass becomes fluorescent, and the “rays” escaping from the tube have the power 
of provoking fluorescence in certain other materials—the diamond, for instance, in 
feeble degree—while potassium platino-cyanide or barium platino-cyanide and 
calcium tungstate in particular can be thrown into a high degree of fluorescence. 
764 ON SKIAGRAPHY, ETC. 
765 
Advantage has been taken of this fact by Edison and others in the construction of 
the so-called fluoroscope, which is nothing but a conveniently shaped box with a 
shield adapted about the eyes, so that no light may enter, while at one end is 
a cardboard which has been spread with mucilage, upon which, before drying, 
crystals of one of the above-mentioned fluorescent salts have been sprinkled. In 
the presence of a Crookes tube, suitably energized, objects which are more or less 
opaque to the Rbntgen rays will cast a shadow upon this fluorescent screen, while 
the soft tissues of the body and many non-metallic objects permit their freer pas- 
sage. Thus a hand held between the screen and the tube will cast a perfect sil- 
houette or shadow, while solid particles, needles, buckshot, pieces of glass, etc., will 
be made conspicuous as upon a photographic plate. 
Several theories have been advanced to account for these phenomena. One 
theory supposes them to be ultra-violet waves of light. According to another, 
they are purely longitudinal ether waves, having no lateral propagations as have 
ordinary light or other waves. A third theory would account 
for them as the result of electrification—i. e. by an electro-static 
effect between the object and the plate, due to the energy pro- 
duced by the excited Crookes tube. A fourth hypothesis is 
that they consist of material particles directly projected from 
the cathode. Tesla, in the Electrical Review of July 8, 1896, 
has announced his view, in accordance with the last sug- 
gestion, that these rays are not vibrations, but actual streams 
of fine particles passing directly through the pores of material 
bodies ; and he has brought forward a special experiment that 
seems to materially strengthen his hypothesis. Certain it is 
that by continued use the electrodes are disintegrated to a 
marked degree, and that discoloration and disorganization of 
the part of the tube bombarded by these particles do take 
place. These particles are so minute as to be able to pass 
through the walls of the bulb, according to Tesla’s view, or else 
tear off* particles from the glass which are themselves projected. 
At all events, impact and consequent injury or shattering seem 
absolutely necessary for their projection. The principal source 
of the rays is certainly the place of first impact. 
Tesla has suggested the following experiment as a cor- 
roboration of his view: “ A single electrode, E, consisting of a 
massive aluminum plate, is mounted on a conductor, C, pro- 
vided with a glass wrapping, W, as usual, and sealed in one of 
the ends of a straight tube, B, about 5 cm. in diameter by 30 
cm. long. The other end of tbe tube is blown out into a thin 
bulb of a slightly larger diameter, and near this end is supported 
on a glass stem, S, a funnel, F, of thin sheet platinum. The 
particular object of the presently described construction was to 
ascertain whether the rays generated at the inner surface of the 
platinum funnel, B\ would be brought to a focus outside of the 
bulb, and, further, whether they would proceed in straight lines 
from that point. For this purpose the apex of the platinum 
cone was arranged to be about 2 cm. outside of the bulb. 
When the bulb was properly exhausted and set in action, the 
glass wall below the funnel, F, became strongly phosphorescent, 
but not uniformly, as there was a narrow ring, RR, on the periph- 
ery brighter than the rest, this ring evidently due to the rays 
reflected from the platinum sheet.” 
When a phosphorescent screen was held outside the bulb 
and shifted to and fro, it was found that the rays did focus. 
This experiment illustrates something more than the mere 
propagation of these rays in straight lines—namely, that the 
fluorescent glass wall, when the platinum was present, emitted 
practically no rays, whereas had the platinum not been present 
it would have been, under similar conditions, an efficient source. 
Tesla explains the absence of radiation from the glass in this 
tube by assuming that the matter proceeding and reflected from the platinum sur- 
face was already in a finely divided state before it reached the glass wall. 
Fig. 450 
Diagram illustra- 
ting Tesla’s ex- 
periments. 766 
SKIAGRAPHY. 
In utilizing the cathodal rays for surgical purposes either the fluoro- 
scope or the photographic plate may be employed. With the former a 
momentary shadow can be obtained without being recorded, by which 
information of much value may often be gained within a few seconds; 
but for permanent record or for purposes of more accurate study photo- 
graphs (i. e. skiagraphs) must be made. For this purpose the ordinary 
dry plate may be employed, certain manufacturers now making plates 
for this special purpose which are considered more sensitive. One of 
these plates in any ordinary plate-holder, of size large enough to accom- 
modate the desired picture, is used according to the necessities of the 
case. 
It will be sufficient for a hand or arm to simply lay it over the plate- 
holder and rest both upon a table, the Crookes tube being fastened above 
the part to be photographed. In the case of a foot the plate may be 
placed upon the floor, the foot rested upon it, and the tube be suitably 
placed. In any event, no metal, such as rings, etc., should be allowed 
to disfigure or render uncertain the picture to be taken. Thus, while it 
is not necessary to take off the stocking, it will be necessary to take off 
a shoe which contains iron nails, a glove with metal buttons, etc. In 
order to avoid lack of definition, it will be well to bandage the limb to 
the plate-holder or to fasten it thereto with strips of adhesive plaster. It 
is not necessary to take off wooden or plaster splints. In the case of 
the trunk the patient may lie upon the plate-holder or a flat table. 
In the case of the skull the plate-holder should be strapped or bound to 
the head, and the whole held in some suitable head-rest because of the 
long exposure required. The time required for exposure can never be 
determined without some experimentation, for it will vary with the size 
of the coil, the voltage of the primary current, the size of the lamp, and 
the degree of vacuum within it. With perfect apparatus good photo- 
graphs of the hand, foot, etc. can be taken in from two to five minutes, 
while with defective apparatus this time may be lengthened to half an 
hour or even an hour. For the body and the skull longer time is 
required—at least with most of the 'apparatus on the market at the date 
of this writing. 
The Crookes tubes become intensely heated at the point of impact of 
the cathode rays, and it is possible to soften the glass to a degree per- 
mitting change of its shape, or to so heat the tube when placed close to 
the patient as to make it uncomfortable or unendurable. For most pur- 
poses a distance of from ten to fifteen inches from the surface is about 
the best. When it is remembered that these rays proceed in straight 
lines, it will be easily seen how much distortion of image may occur 
when the endeavor is made to skiagraph too extensive an area with one 
tube. On the other hand, with two or more there may be some con- 
fusion of images. The method in general use for skiagraphing a hand 
can be seen from the accompanying illustration (Fig. 451). 
Dr. W. J. Morton of New York made the discovery that the dis- 
ruptive discharges of static electricity could be taken advantage of in 
skiagraphy, and that shadow pictures could be taken without the use of 
the Crookes tubes. He also found that better results could be secured 
by the use of Leyden jars, charged by Holtz’s machine and discharged 
into the vacuum bulb. In this way he has been able to use tubes of ON SKIAGRAPHY, ETC. 
767 
twenty inches in diameter without danger of breaking their walls. By 
their use he seems to get more rapid oscillations, computed at fifteen 
millions to the second. While Morton thinks that the best promise for 
Fig. 451. 
Illustrating method of skiagraphy by use of large induction coil. 
the future lies in the use of large Holtz machines, he at present uses no 
Leyden jars, but does use a vacuum tube. He has succeeded in getting 
good pictures with the ordinary radiometer of large size fitted with tin- 
foil electrodes. Most operators use large induction coils capable of 
throwing a spark at least eight inches. The efficiency (i. e. insulation) 
of the coil is greatly enhanced by immersing it in oil. 
Quite recently, at the date of present writing, Le Bon has discovered another 
manifestation of energy, which he calls “ la lumiere noire.” It is quite certain 
that the retinae of different animal forms are sensitive to light in different ways and 
to different degrees. There is every reason to think that certain rays of the spectrum 
which do not affect the human retina do nevertheless affect the retinae of many 
of the lower forms of animal life, just as it is known that the ultra-violet rays, 
invisible to the eye, will yet affect the sensitive plate. The terms “visible” 
and “ invisible ” are therefore purely relative. Invisible light—if one may use the 
expression—may, then, come through the cathode of a Crookes tube as well as the 
Rbntgen rays, or may be produced from other sources. 
Le Bon has recently presented to the Academy of Sciences in Paris the follow- 
ing experiment: An ordinary photographic negative with a developed image is 
placed over a sensitive plate inside of a light-proof wrapping. The whole appa- 
ratus is then covered by a metallic sheet and exposed to the light of a petroleum 
lamp for about three hours; after which energetic development of the sensitive 
plate will give a faint image of the negative. If behind the sensitive plate he 
placed a thin sheet of lead and in front of it a sheet of iron, the same exposure to 
the same light would give an excellent image instead of a faint one, providing 
that the two metal coverings were brought in contact. Le Bon thinks that the 
contact of two different metals gives rise to a slight electric current, whose action, 
combined with that of the petroleum lamp, makes the plate more pervious to the 
light. Solar light is said to give the same results, while zinc, silver, and tin, and 
particularly black paper, are more resistant. While cathodic rays pass easily 
through the latter, the invisible rays cannot. 
Of the practical applications of Rbntgen’s discovery the profession 
have been made pretty generally aware through numerous publications 
in current medical literature. Up to the present their most common 768 
SKIAGRAPHY. 
application lias been for the purpose of skiagraphing the bones or of 
detection of foreign bodies—needles, etc.—in the soft parts. By means 
of Rontgen’s discovery it will be hereafter possible to recognize irregu- 
larities, deformities, new growths, malformations, the existence of frac- 
tures or dislocations, the character of pseudarthroses, variations in den- 
sity of bone, size and location of sequestra, etc., in at least the bones of 
the limbs. Much may be told also regarding the perfection of union and 
solidity of callus after fracture, and even changes which have taken 
place in the dimensions of the marrow-cavity. By mere study of the 
osseous skeleton, alone, of mother and foetus the obstetrician may accu- 
rately depict the position of the foetus shortly before birth. Probably 
the fluoroscope will suffice for this purpose, it not being often necessary 
to take a skiagraph. 
Inasmuch as mineral matter is the more impervious to these rays, 
calcareous infiltration of various organs or tissues causes marked rela- 
tive differences which the expert will in time learn to recognize. Thus, 
calcareous infiltration of arteries and atheromatous disease may be made 
actually visible. The exact progress of ossification and of epiphyseal 
union in the bones of children may also be depicted quite accurately, 
as well as pathological changes in bone tissue, callus, etc. 
For the same reason mineral calculi can be made visible, particularly 
in the bladder and kidneys; probably also in the ureters, the salivary 
ducts, etc. On the other hand, calculi composed of organic material, 
like cystin, and biliary calculi seem strangely pervious to these rays, 
and are as yet not easily capable of detection by their means. For the 
dentist fangs of teeth and foreign bodies, as well as the presence of un- 
suspected fillings, may be clearly indicated, and the presence of super- 
numerary or non-erupted teeth. 
It is in the detection of foreign bodies, especially metallic, that 
the skiagraph and fluoroscope are often of greatest value. Gunshot 
missiles of all sizes, from buckshot up to bullets, needles and par- 
ticles of metal, glass, etc., are capable of easy detection by this means. 
During the present year a jack-stone, which had become impacted in the 
oesophagus of a little child, Avas exactly located and its rentoval very 
much facilitated by a skiagraph taken by Dr. White of Philadelphia. 
With improvement in technique differences may be quickly made 
out in the soft parts which we are as yet rarely able to accurately 
recognize—for instance, the location of the heart, the liver, etc.—while 
with the fluoroscope and the energetic tube the movements of the viscera 
may be seen within the cavities of the body during life. 
It does not seem necessary to go into further details, but the reader is 
referred to the plates herewith subjoined for information which may 
illustrate some of the uses of Rontgen’s ray in surgery. 
Just at the date of penning this chapter Levy of Berlin lias announced the 
construction of a new Crookes tube, with which he claims to be able to inspect the 
interior of the antrum, the frontal sinuses, the larynx, and the viscera by using 
the fluorescent screen. It consists of a vacuum tube with concave electrodes, 
with a disk of platinum, tilted at 45°, midway between them; this is made the 
cathode, while the anode is a double one. With this instrument arterio-sclerosis 
of the large vessels, both in the trunk and the limbs, could be recognized, while 
shadows were made by calcareous degeneration of old lesions in the lungs and 
pleune. Enlargement of the heart was also made visible. PLATE XIV. 
Clubfoot, Child aged Six Years, showing Overlapping of the Metatarsals ; patient of 
Dr. De Forest Willard, by whose permission the illustration is used. 
[Skiagraphed by Prof. Arthur W. Goodspeed. Copyright 1896, by William Beverley Harison.] PLATE XV. 
Skiagraph of the Hand of a Young Lady, aged Twenty-six Years, showing a Needle 
Imbedded in the Muscles for Twenty Years. 
[Skiagraphed and loaned by Mr. Herbert B. Shali.enberger, Rochester, Pa. Exposure, 5 minutes.] PLATE XVI. 
An Old Dislocation of the Wrist, with Fracture and Disappearance 
of the Styloid Process of the Ulna. 
Note the darker shadows of the pisiform bone and the unciform process. 
[Skiagraphed and loaned by Mb. Herbert B. Shallenberger, Rochester, Pa. Exposure, 40 minutes.] Skiagraph of Thorax and Arms. 
Observe especially the Cervical Intervertebral Substances, Ribs, Clavicles, and Shoulder-joints. 
[Skiagraphed by Prof. A. W. Goodspeed, and kindly loaned by Dr. H. W. Cattell. 
From the International Medical Journal. Equal definition in one minute.] INDEX. 
ABDOMEN, distention of, in peritonitis, 
385 
exploration of, for jaundice, 405 
surgery of, 339 
wall of, contusions of, 339 
injury to contained viscera from, 339 
gall-bladder, 341 
intestine, 340 
spleen, pancreas, liver, 341 
stomach, 340 
gunshot wounds, 342 
of abdominal viscera, 343, 344 
treatment, 343 
penetrating wounds, 342 
hemorrhage from, 342 
prolapse following, 342 
wounds of, followed by hernia, 417 
Abdominal abscess, 347 
injuries without penetration, 339 
pregnancy, 560 
wall, contusions of, 339 
luematoma of, 339 
Abernethy’s method of ligation of external 
iliac artery, 151 
Abscess, abdominal, 347 
about bladder, 494 
alveolar, 327 
appendicular, abnormal situations of, 378 
operation for, 379 
of brain, 52 
prognosis, 54 
symptoms, 53 
treatment, 60 
of breast, 568 
incisions in, 568 
intramammary, 568 
retro- or submammary, 568 
superficial, 568 
symptoms, 568 
of glands of Bartholin, 524 
of hip, mechanical treatment of, 681 
laryngo-tracheal, 241 
of liver, 399 
causes, 399 
amoeba coli, 399 
diagnosis, 400 
diagnosis, 400 
pysemic, 400 
treatment, 400 
of lung, 279 
diagnosis, 279 
treatment, 279, 280 
tubercular, 280 
of omentum, 391 
Abscess of pancreas, 394 
symptoms, diagnosis, prognosis, 394 
treatment, 394 
of parametrium, 556 
psoas, 99 
of rectum, 442 
classification, 442 
ischio-rectal, 442 
treatment, 443 
superior pelvi-rectal, 443 
treatment, 444 
retroperitoneal, from pancreas, 394 
retropharyngeal, 182, 247 
symptoms, 182 
treatment, 183 
of spleen, 396 
symptoms, diagnosis, treatment, 397 
subphrenic, 274, 346 
causes of, 274 
symptoms, 275, 346 
treatment, 276, 347 
Acbeilia, 219 
Actinomycosis of chest-wall, 294 
of jaw, 329 
of lip, 317 
of tongue, 321 
Adhesions of intestines causing obstruction, 
356 
Aeroceles, 235 
Air-embolism in wounds of neck, 232 
Air-passages, burns of, 160 
foreign bodies in, 161 
Alexander’s operation, 539 
Allingham’s operation for hemorrhoids, 435 
Alveolar abscess, 327 
Amazon thorax, 564 
Ambulatory treatment of hip disease, 676 
“American operation” for haemorrhoids, 
435 
Amoeba coli in hepatic abscess, 399 
Amputations, 589 
classification, 589 
arm, 604 
elbow, 602 
fingers, 599 
foot, 607 
forearm, 602 
hand,601 
hip joint, 620 
interscapulo-thoracic, 606 
knee, 616 
leg, 612 
shoulder, 604 
thigh, 617 
769 770 
INDEX. 
Amputations, classification, toes, 607 
in compound fractures, 590 
Crede’s method of dressing and approxi- 
mation, 595 
in doubtful cases, 590 
drainage in, 594 
dressings of stump in, 594 
general considerations, 589 
instruments required for, 591-594 
local indications, 590 
lower extremity, foot, 607 
artificial limb, 607, 608 
atypical conservative operations, 
612 
Link’s, 612 
medio-tarsal (Chopart’s), 609 
modifications, 610 
partial, 608 
metatarsal, 608 
subastragaloid disarticulation, 610 
modifications, 611 
tarso-metatarsal (Lisfranc’s), 608 
modification, 609 
tibio-tarsal (Syme’s), 611 
modifications (Pirogofl’s), 611 
hip-joint, disarticulation, 620 
flap formation, 622 
haemostasis, 621 
Wyeth’s method, 621 
knee, disarticulation, 616 
methods, 617 
Stephen Smith’s “ hooded ” flap, 
617 
leg, 612 
Bruns’ method, 615 
methods, 613 
atypical, 615 
point of election, 614 
supramalleolar (Guyon’s), 613 
thigh, 617 
shaft and upper portion, 619 
methods, 619 
Neudorfer’s, 620 
through condyles, 617 
methods, 617 
Carden’s transcondyloid, 617 
Gritti’s osteoplastic, 618 
intercondyloid osteoplastic 
(SabanejefF), 619 
toe, 607 
big, 607 
disarticulation of, at metatarso- 
phalangeal joint, 607 
with corresponding metatarsal, 607 
methods of, 595 
elliptical, 598 
flap, 598 
manner of cutting, 598, 599 
oral or racket, 597, 598 
selection of method, 596 
subperiosteal excision, 599 
Teale’s, 599 
transverse circular, 597 
solid musculo-tegumentary, 597 
skin-cufF, circular (a la manchette), 
597 
mortality from, 623 
Amputations, mortality from, causes, imme- 
diate, 623 
secondary, 623 
in modern period, 623 
stump after bad, 624 
good, 624 
care of, during healing, 625 
interval before application of artificial 
limb, 625 
upper extremity, arm, 604 
elbow, disarticulation of, 602 
fingers, 599 
corresponding metacarpals, 600 
entire, 600 
two or more adjoining simulta- 
neously, 600 
forearm, 602 
band, radio-carpal disarticulation, 
601 
interscapulo-thoracic, 606 
shoulder, disarticulation, 604 
Anastomosis of intestine, 373 
technique of, 374 
of cranial bones, 20 
Anatomy of breast, 563 
Aneurism, arterio-venous, intracranial, 47 
Ankle-joint disease, treatment of, 684 
Ankylo-blepharon, 721 
treatment, 722 
Ankylo-cheilia, 219 
Ankylosis, 673 
treatment, 673 
of jaws, 330 
Antiseptics, urinary, 479, 579 
Antrum of Highmore, empyema of, 329 
Anus, artificial, 368 
mortality in hernia, 423 
chancre, 448 
chancroids of, 448 
fissure of, 446 
mucous patches of, 449 
imperforate, 432 
Aorta, abdominal, ligation of, 148 
Aplasia cranii, 20 
Apoplexia neonatorum, 47 
Appendectomy, 381 
indications for, 381 
McBurney’s method, 381 
Appendicitis, acute, 375 
course and prognosis, 376 
diagnosis, 378 
etiology of, 375 
pathology of, 376 
symptoms, 377 
time for operation in, 379 
treatment, medical, 378, 380 
surgical, 379 
technique of, 379 
bacteriology of, 377 
catarrhal, 380 
salines in, 380 
causing acute obstruction, 360 
chronic, 380 
symptoms, 380 
treatment, 381 
relapsing, 380 
Appendix, vermiform, diseases of, 375 INDEX. 
771 
Appendix, vermiform, anatomy of, 375 
inflammation of, acute, 375-381 
treatment, 378, 380 
chronic, 380 
treatment, 381 
inflammatory adhesions about, 379, 380 
removal of, indications for, in period of 
health, 381 
operation for (McBurney’s), 381 
Aprosopia, 202 
Arachnoid, tumors of, 117 
Arlt’s operation of blepharoplasty, 709 
Arm, amputation of, 604 
forearm, amputation of, 602 
Arteries, ligation of, 133 
abdominal aorta, 148 
axillary, 143 
brachial, in middle of arm, 144 
at bend of elbow, 144 
common carotid, 136 
iliac, 148 
dorsalis pedis, 157 
external carotid, 137 
iliac, 150 
facial, 139 
femoral, 151 
common, 151 
superficial, at apex of Scarpa’s tri- 
angle, 152 
in Hunter’s canal, 153 
gluteal, 149 
inferior thyroid, 140 
innominate, 135 
internal carotid, 140 
iliac, 149 
pudic, 149 
lingual, at its first part, 138 
occipital, 140 
peroneal, 155 
popliteal, 153 
radial, 145 
sciatic, 149 
subclavian, 141 
superior thyroid, 138 
temporal, 140 
tibial anterior, 155 
posterior, 153 
behind malleolus, 155 
ulnar, 146 
vertebral, 140 
technique in ligation of, 133-135 
Artery, carotid, intracranial, injury of, 46 
wounds of, 251 
intercostal, wounds of, 268 
internal mammary, wounds of, 269 
treatment, 270 
middle meningeal, hemorrhage from, 46 
subclavian, wounds of, 254, 255 
vertebral, aneurism of, 256 
Arthrodesis of ankle-joint in paralysis, 669 
Artificial arms, 368 
legs, importance of stump in, 608 
limbs, application to stump, 625 
Astomia, 219 
Atelo-prosopia, 202 
Atresia of pylorus, 349 
of urethra, 458 
Atresia of vagina, 522 
treatment, 523 
Atrophic cancer of Billroth, 581 
Atrophy of cranial bones, 20 
Auditory canal, inflammations of, 754 
exostoses of, 755 
foreign bodies in, 753 
treatment, 754 
granu lorn ata of, 756 
Auricle, congenital deviations of, 749 
fracture of, 750 
malformations of, 749 
treatment, 749 
othsematoma of, 751 
surgery of, 749 
tumors of, 752 
epithelioma, 752 
wounds of, 750 
Autoplasty, 686 
Axillary artery, ligation of, 143 
BACILLUS COLI COMMUNIS, in ap- 
pendicitis, 377 
in peritonitis, 385 
Bacteria found in appendicitis, 377 
of mouth, 312 
causing dental caries, 327 
in strangulated hernia, 410 
Bacteriology of peritonitis, 385 
Basedow’s disease, 245 
Base line of skull in cranial topography, 74 
Bassini’s method of radical cure of inguinal 
hernia in male, 424 
Bell’s palsy, 207 
Berger-Farabeuf, operation for interscapulo- 
thoracic amputation, 606 
Biliary colic, 402, 403 
Billroth’s method for removal of tongue, 324 
Bladder, congenital absence, 460 
division, 460 
extrophy, 461 
hernia, 460 
inversion, 460 
malformations, 460 
diseases of, 487 
diverticula, hernia of, 419 
examination of, 470 
inflammation about (pericystitis), 494 
of prostate, cystitis, 488 
of viscus, 487 
causes of, 487, 488 
symptoms, 488 
treatment, 488 
injuries to, 464 
with perforation, 465 
extraperitoneal rupture of, 466 
treatment, 466 
intraperitoneal rupture, 465 
treatment, 466 
without perforation, 464 
stone in, 488 
conditions whicli favor formation, 489 
diagnosis, 489 
symptoms, 489 
treatment, 490 
litholapaxy, 490, 491 
lithotomy, lateral, 490 772 
INDEX. 
Bladder, stone in, treatment of, lithotomy, 
median, 490 
suprapubic, 490, 491 
tuberculosis of, 494 
tumors of, 492 
diagnosis, 493 
treatment, 494 
Blepharoplasty, 709 
Arlt’s operation, 709 
Knapp’s, 712 
Richet’s, 709 ' 
Bougie, oesophageal, 308 
Bougies, filiform, in treatment of stricture, 
477 
Bowel integrity in hernia, 422 
Bow-legs, 645 
Brachial artery, ligation of, at middle of 
arm, 144 
at bend of elbow, 144 
plexus, operations on, 124 
wounds of, 255 
Bradford’s bed-frame, 103, 104, 674 
Brain, abscess, 52 
prognosis in, 54 
treatment, 60 
compression of, 41 
causes of, 42 
differential diagnosis of cause, 42 
treatment, 44 
concussion of, 39 
treatment, 40 
contusion of, 40 
differential diagnosis of, 41 
post-mortem appearances in, 40 
treatment of, 41 
injuries to, 38 
Brain-substance, lacerations and injuries, 47 
treatment of, 49 
hernia of, 49 
treatment of, 50 
prolapsus of, 49 
Branchial clefts, embryology of, 311 
fistula*, 210, 220, 231, 228, 231, 234, 238, 
246, 250, 311 
of cheeks, 228 
of face, 210 
of lips, 220 
of neck, 231 
Breast, abscess of, 567 
incisions in, 568 
intramammary, 568 
retro- or submammary, 568 
superficial, 568 
anatomy of, 563 
anomalies of, 564 
cysts of, 574 
retention of, 574 
treatment, 575 
development of, 563 
examination of, for tumors, 569 
hemorrhage from, vicarious menstruation, 
565 
hypertrophy of, 573 
inflammation of, acute, 567 
time of occurrence, 567 
treatment, 567 
chronic, 569 
Breast, inflammation of, chronic, differential 
diagnosis for carcinoma, 569 
treatment, 570 
lymphatics of, 504 
neuralgia of, 573 
treatment, 573 
nipple and areola, diseases of, 565 
fissure of, 566 
inflammation, 565 
operations on, 584, et seq. 
j skin diseases of, 565 
strapping of, 566 
surgical injuries and diseases of, 563 
syphilis of, 572 
chancre, 572 
secondary manifestations, 572 
tertiary manifestations, 572 
treatment, 573 
tuberculosis of, 570 
diagnosis, 571 
differential, 571 
treatment, 571 
tumors of, 574 
adenoma, 575 
carcinoma, 577 
acinous, 577 
atrophic cancer of Billroth, 581 
cachexia in, 583 
diagnosis of, 582 
infiltration of tissue in, 579 
cancer en cuirasse, 580 
lymphatics in, 581 
metastasis in, 583 
treatment for, 586 
Halsted’s operation, 586 
for inoperable cases, 587 
tubular, 578 
degenerations in, 574 
innocent, treatment of, 585 
sarcoma, 576 
diagnosis of, 576 
wounds and burns, 565 
Broad ligament of male, disease of, 479 
inflammation and suppuration about, 
494 
I Brophy’s method of early operation for 
closure of cleft palate, 333 
; Brisement force, 674 
Bruns’ and Langenback’s method of repair 
of quadrangular defects, 697 
method of amputation of leg, 615 
Bubo, chancroidal, 519 
treatment, 521 
Bunion, 671 
j Burns of air-passages, 160 
of mouth, 313 
I Burow’s method of repair of triangular de- 
fects, 694 
quadrangular defects, 696 
pACHEXIA STRUMIPRIVA, 243 
i \J Calculi of pancreas, 395 
Calculus in bladder, 488 
treatment, 490 
choice of methods, 490 
litholapaxy, 490, 491 
lithotomy, 490 INDEX. 
773 
Calculus in kidney, 498 
treatment, 500 
Cancer of breast, differential diagnosis from 
chronic mastitis, 569 
en cuirasse, 580 
serum of Emmerich and Zimmerman, 588 
Cancrum oris, 317 
Caput succedaneum, 24 
Carbolic acid in treatment of hemorrhoids, 
434 
Carbuncle of scalp, 17 
Carcinoma of breast, cachexia in, 583 
infiltration of tissue in, 579 
lymphatics in, 581 
metastasis in, 583 
treatment, 586 
Halsted’s method, 586 
for inoperable cases, 587 
of intestine, causing obstruction, 364 
treatment, 366 
of rectum, radical treatment for, 453 
of uterus, 550 
treatment, 551 
Carden’s transcondylar amputation of thigh, 
617 
Cardicentesis, 131 
Caries, dental, 326 
causes, symptoms, and treatment, 327 
vertebral, 94 
Carotid artery, common, ligation of, 136 
external, ligation of, 137, 214 
internal, ligation of, 140 
Carus pectinatum, 260 
Castration for enlarged prostate, 485 
for fibroids of uterus, 550 
Cataract, 732 
treatment, 733 
Catheterization in treatment of enlarged 
prostate, 483 
Catheters, care of, 483 
Cellulitis of scalp, 17 
Celluloid plates in repair of bony defects, 
64, 78 
Cephalalgia, surgical treatment of, 71 
Cephalhematoma neonatorum, 24 
Ceplialocele, 62 
treatment, 64 
Cerebral membranes, inflammation of, 66 
Cervix, laceration of, 541 
treatment, 542 
surgery of, 541 
Chalazion, 702 
Chancre of anus, 448 
of breast, 572 
differential diagnosis from chancroid, 520 
of urethra, 472 
Chancroid, 519 
bubo in, 519 
differential diagnosis from chancre and 
herpes, 519, 520 
extragenital, 521 
infectiousness of, 520 
mixed, 521 
phagedenic, 519 
prognosis, 520 
treatment, 521 
Chancroids of anus and rectum, 448 
Chassaignac’s subangulo-maxillary adeno- 
cellulitis, 247 
Cheeks, injuries to, 228 
malformations and fissures of, 228 
surgery of, 228 
tumors of, 230 
j Cheiloplasty, 318 
Chest, contusions of, 262 
treatment, 263 
emphysema of, 271 
injuries of, 262 
heart, 270 
hemorrhage in, 265 
intercostal artery, 268 
internal mammary artery, 269 
treatment, 270 
lung, rupture of, 268 
mediastinum, 267 
pericardium, 270 
pleura, 267 
thoracic duct, 270 
wounds of, 263 
treatment of, 263 
gunshot, 264 
non-penetrating, 264 
treatment, 264 
penetrating, 264 
treatment, 265 
lung, diseases of, 278 
malformations of, 257 
acquired, 257 
causes of, 257-262 
congenital,- 257, 261 
mediastinum, injuries and diseases of, 
276-278 J 
neuralgia, intercostal, 271 • 
surgery of, 257 
injuries and wounds of, 264 
tattooing of, 262 
walls, diseases of, 272 
Chin, malformations of, 227 
Cholecystcolostomy, 406 
Cholecystectomy, 406 
Cholecystenterostomy, 406 
Cholecystotomy, 405 
Cholelithiasis, 402 
treatment, 405 
Chopart’s amputation of foot, 609 
Circumcision, 511 
Clamp and cautery operation for hemor- 
rhoids, 435 
Cleft-palate, Brophy’s operation for relief 
of, 333 
indications for early closure, 333 
technique, 334 
after-treatment, 336 
Club-foot, 650 
treatment, manipulation, 653 
extreme force, 655 
mechanical apparatus, 653 
open incision, 655 
plaster-of-Paris, 653 
resection, 655 
tenotomy, 654 
Club-hand, 656 
treatment, 657 
Coccygeal dimple and sinus, 85 774 
INDEX. 
Coccygeal dimple and sinus, treatment, 85 
Coccygodvnia, 118 
Coccyx, removal of, 115 
Cceliotomy, 387 
Coley’s method of treatment for inoperable 
malignant growths, 587 
Colic, renal, 504 
Coloboma, 219, 702 
Colo-cholecystostomy, 406 
Colon bacillus as a cause of appendicitis, 377 
of hepatic abscess, 399 
Colostomy, 450 
hernia following, 452 
indications for, 450, 456 
lumbar, 452 
technique of, 450, 451 
time for opening bowel in, 451, 452 
Colporrhaphy, 539 
Common duct, impaction of, 403 
operation on, 406 
stricture of, 404 
Commotio thoracica, 262 
Compression of brain, 41 
Concussion of brain, 39 
of spine, 94 
Conjunctiva, diseases of, 712 
ankyloblepharon, 721 
treatment, 722 
herpes zoster ophthalmicus, 717 
inflammation of, diphtheritic, 712 
granular, 713 
treatment, 714 
phlyctenular, 717 
morbid growths of, 718 
dermoids, 719 
epithelioma, 719 
sarcoma, 720 
syphilis, 718 
pemphigus of, 718 
pterygium, 715 
treatment, 716 
purulent opthalmia, 712 
treatment, 714 
symblepharon, 720 
treatment, 720 
Teale’s operation, 721 
xerophthalmia, 718 
Conjunctivitis, diphtheritic, 713 
granular, treatment, 714 
phlyctenular, 717 
purulent, 712 
treatment, 713 
Contre-coup, 35 
Contusion of brain, 40 
of spine, 94 
Cooper’s (Sir Astley) method of ligating 
exteral iliac artery, 150 
Cornea, conical, 726 
diseases of, 726 
staphyloma of, 726 
tumors of, 727 
Coxa vara, 644 
Cranial bones, inflammation of, 23 
injuries of, 27 
necrosis of, 24 
osteomyelitis of, 23 
periostitis of, 23 
! Cranial bones, wounds of, 27 
nerves, fifth, 51 
injuries of, 50 
oculo-motor, 51 
olfactory, 50 
optic, 50 
seventh and eighth, 51 
topography, 73 
Craniectomy, 68 
Craniotabes, 22 
Craniotomy, 68 
Cranium, injuries of the soft parts of, 26 
meningitis, 57 
classification, 57 
pachymeningitis externa, 57 
interna, 58 
leptomeningitis, 58 
operations on, 73 
penetrating and incised wounds of, 26 
treatment, 27 
septic infections within, 51 
abscess of brain, 52 
treatment, 60 
encephalitis, 59 
treatment, 60, 61 
sinus phlebitis, 56 
treatment, 61 
thrombosis, 55 
treatment, 61 
topography of, 73 
trephining, 74 
drainage after, 79 
indications for, 77 
repair of opening, after, 78 
Crede’s method of treatment of flaps after 
amputation, 595 
Cryptorchidism, 461 
dangers of, 461 
Cushing’s method of intestinal suture, 370 
Cyst, hydatid, of lung, 282 
Cystic duct, operation in, 406 
Cystitis, 487 
acute phlegmonous, of gall-bladder, 403 
urinary, treatment, 488 
Cystocele, 538 
Cvstoscope, 490, 493 
Cysts of breast, 574 
of glands of Bartholin, 524 
of kidney, 502 
of lachrymal gland, 723 
of liver, 401, 402 
hydatid, 401 
of mesentery, 393 
i of omentum, 391 
of ovary, 552 
dermoid, 553 
of pancreas, 395 
treatment, 396 
retention, of tongue, 372 
sacral, 84 
Czerny-Lembert intestinal suture, 369 
DACYRO-ADENITIS, 722 
Dacyro-cystitis, 724 
treatment, 725 
Defects, lanceolated, elliptic, and semilunar, 
repair of, 698 INDEX. 
775 
Defects, quadrangular, repair of, 695 
trapezoid, repair of, 697 
triangular, repair of, 693 
Dental caries, 326 
Dermatoplasty, 686 
Diaphragm, diseases of, 300 
congenital defects of, 298 
hernia of, 300 
treatment, 301 
injuries of, 266, 298 
rupture of, 298 
treatment, 300 
tumors of, 300 
Diaphragmatic hernia, 300, 417 
Dieffenbach’s method of repair of triangular 
defects, 693 
Dilatation, gradual, for organic stricture of 
urethra, 475 
rapid, for organic strictures, 477 
Dislocation, congenital, of hip, 640 
treatment, 642 
traction, 642 
operation, 642 
Hoffa’s method, 643 
Lorenz method, 643 
Paci method, 643 
of hyoid bone, 240 
of nasal cartilage, 200 
of nerves, 125 
of nose, 218 
of spine, 90 
treatment, 91 
of spleen, 397 
Distichiasis, 708 
Diverticula of oesophagus, 302 
Doleris’ operation for incomplete laceration 
of perineum, 530 
Dorsalis pedis artery, ligation of, 157 
Drainage, abdominal, followed by hernia, 
428 
after amputation, 594 
of bladder, 484 
in peritonitis, 388 
permanent, for hydrocephalus, 65 
in subphrenic abscess, 347 
Duct, common, stricture of, 404 
operation on, 406 
impaction of, 403 
cystic, operation on, 406 
hepatic, operation on, 406 
thoracic, wounds of, 270 
thyroglossal, embryology of, 311 
Duke’s operation for incomplete laceration 
of perineum, 531 
Dysenteric abscess of liver, 399 
ulceration of rectum, 447 
Dyspnoea as a sign of tumor of lung or 
pleura, 286 
EAR, auricle, congenital deviations of, 749 
fracture of, 751 
malformations, 749 
treatment, 749 
othsematoma of, 751 
treatment, 751 
tumors of, 752 
wounds of, 750 
Ear, external canal, exostoses of, 755 
foreign bodies in, 753 
treatment, 754 
inflammatory processes in, 754 
membrana tympani and tympanum, 756 
granulations in, 7 59 
hemorrhage into, 756 
mastoid operation, 760 
incision and technique of, 762 
operations within middle ear, 757 
for acute inflammation of middle ear, 
758 
for removal of membrane, malleus, 
incus, 758 
polypi in, 769 
rupture of, 756 
surgery of, 749 
Echinococcus cyst of kidney, 503 
of liver, 401 
of lung, 282 
Ectopic pregnancy, 559 
abdominal, 560 
rupture, symptoms of, 561 
treatment, 561 
elytrotomy, 561 
laparotomy, 561 
situations, 559 
tubal pregnancy, 560 
tubo-abdominai, 560 
tubo-uterine, 560 
Ectropion, 708 
Eighth nerve, injury of, 51 
Ejaculation, pain during, 518 
Elbow, disarticulation of, 602 
methods, 603 
Elbow-joint disease; mechanical treatment 
of, 685 
Electrolysis in treatment of uterine fibroids, 
545 
Pilytrotomy, 561 
Embolism and thrombosis of mesentery, 392 
Emmet’s operation for complete laceration 
of perineum, 535 
for incomplete laceration of perineum, 
529 
Emphysema of chest, 271 
treatment, 272 
Empyema of antrum of Highmore, 329 
treatment, 329 
causing malformation of chest, 258, 259 
of pleural cavities, thoracotomy for, 288 
Encephalitis, 59 
treatment, 60, 61 
Encephalocele, 62-64 
treatment, 64 
Endocranitis, 57 
Enlargement of prostate, 481 et seq. 
Enterocele, 408 
Entero-cholecystostomy, 406 
Entero-epiplocele, 408 
Enteroliths causing intestinal obstruction, 
358 
Enteroplasty, 375 
Enterostomy, 374 
Enthesis, 687 
Entropion, 706 
treatment, 706 776 
INDEX. 
Epicanthus, 701 
Epididymis, chronic inflammation of, 507 
treatment, 507 
tuberculosis of, 506 
Epididymitis, 507 
treatment, 507 
Epigastric hernia, 416 
Epiglottis, injuries of, 180 
wounds of, 246 
Epilepsy, surgical treatment of, 69 
Epiplocele, 408 
Epispadias, 460 
Epistaxis, 194 
treatment, 195 
Epithelioma of lip, 317 
treatment, 318 
of penis, 471 
of tongue, 322 
treatment, 323 
Erection, feeble, causes of, 516 
Erysipelas prodigiosus toxines in treatment 
of inoperable malignant growths, 
587 
of scalp, 17 
Esmarch’s method of haemostasis, 592 
Esthiomene, 488 
Estlander’s cheiloplastic operation, 227 
Ethmoid sinus, diseases of, 198 
Examination of patient in genito-urinary 
disease, 469 
Excision of tongue, complete, Billroth’s 
method, 324 
Kocher’s method, 324 
Langenbeck’s method, 325 
Rignoli’s method, 325 
Sedillot’s method, 325 
partial, 323 
Exophthalmic goitre, 245 
Exophthalmos, pulsating, 740 
treatment, 742 
Extra-uterine pregnancy, 559 
abdominal, 560 
rupture of, 561 
treatment, 561 
tubal, 560 
tubo-abdominal, 560 
tubo-uterine, 560 
Extravasation of urine, 462-464 
Extrophy of bladder, 461 
Eye, surgical affections of, 701 
Eyeball, inflammation of, 733 
treatment, 734 
Eyelids, congenital deformities of, 701 
coloboma, 702 
epicanthus, 701 
cysts of, 703 
diseases of, 701, 704 
distichiasis of, 708 
ectropion, 708 
treatment, blepharoplasty, 709 
Arlt’s, 709 
Richet’s, 709 
entropion, 706 
treatment, 706 
Graefe’s operation, 707 
Jaesche-Arlt operation, 707 
inflammation of, 702 
Eyelids, muscles of, affections of, 704 
paralysis of orbicularis, 705 
levator palpebrse superioris, 705 
treatment, 705 
spasm, 704 
plastic operations on, blepharoplasty, 709 
Arlt’s operation, 709 
Dieffenbach’s operation, 710 
Knapp’s method, 712 
Richet’s operation, 799 
trichiasis of, 708 
tumors of, 702 
malignant, 704 
Eyes, muscles of, external, affections of, 747 
nystagmus, 748 
paralysis of external ocular muscles, 
748 
strabismus, 747 
FACE, actinomycosis of, 211 
burns of, 205 
contusion of, 205 
cysts of, 212 
dermatological affections of, 202, 203, 204, 
207 
deviation, acquired, 205 
diseases and injuries of, 202 
epithelioma, 209 
fistulae of, 210 
freezing of, 205 
gangrene of, 208 
gunpowder stains of, 206 
gunshot wounds of, 206 
infective granulomata of, 209 
lymphangeiomata of, 211 
malformations, congenital, 202 
acquired, 203 
myxcedema of, 204 
neuroses, 207 
operations on, 214 
paralysis of, 207 
scrofuloderma of, 210 
septic infection of, 207, 208 
syphiloderma of, 210, 213 
tuberculoderma of, 208, 209, 210 
tumors of, 21 i, 213 
ulcers of, 208 
wounds of, 205 
complications of, 206 
poisoned, 207 
sequels to, 206 
Facial artery, ligation of, 139 
nerve, injury to, 119 
Facies ovariana, 554 
Fallopian tubes, inflammation of, 558 
treatment, 559 
pin in, 559 
treatment, 559 
Fecal fistula, 368 
Femoral artery, ligation of common, 151 
superficial, at apex of Scarpa’s trian- 
gle, 152 
in Hunter’s canal, 153 
hernia, 415 
radical cure of, Bassini’s method, 429 
Fergusson’s method of resection of upper 
jaw, 332 INDEX. 
777 
Fibroids of uterus, 542 
Fifth nerve, injury of, 51 
operations on, 122 
Fingers, amputation of, 599 
with corresponding metacarpals, 600 
Fissure of anus, 446 
of Rolando, topography of, 73 
of Sylvius, topography of, 74 
Fistula, fecal, 368 
treatment, 368 
Fistula1, gastric, 347 
of rectum, 444 
treatment, 446 
tubercular, 445 
Flat-foot, 658 
Floating kidney, 503 
liver, 399 
Foot, amputation of, 606, 607 
atypical operations, 612 
partial, 607 
medio-tarsal, 609 
metatarsal, 608 
subastragaloid, 610 
tarso-metatarsal, 608 
total (tibio-tarsal), Syme’s, 611 
Pirogoff’s, 611 
arch of, affections of, 657 
flat-, 658 
treatment, 661-665 
pronated, 657 
treatment, 661-663 
Forces causing chronic intestinal obstruc- 
tion, 367 
Foreign bodies in appendix vermiformis, 
376 
in brain, 48 
causing intestinal obstruction, 358 
in external auditory canal, 753 
treatment, 754 
in larynx, 161 
in oesophagus, 304 
in orbit, 738 
in pharynx, 183 
in salivary passages, 246 
in stomach, 349 
in thorax, removal of, 266 
in trachea, 161 
Fracture, gunshot, of skull, 29 
of hyoid bone, 240 
of larynx, 159 
treatment, 160 
of nasal septum, 199 
of nose, 218 
of skull, 28 
of base, 34 
treatment, 37 
by contre-coup, 35 
of vertex, 31 
treatment, 32 
of spine, 85 
differential diagnosis from injuries of 
cord, 87, 88 
treatment of, 89 
non-operative, 90 
operative, 89 
of thyroid cartilage, 240 
of trachea, 241 
Frambcesia, 209 
Frontal sinus, disease of, 198 
Funicular hernia, 413 
GALL-BLADDER, 402 
acute phlegmonous inflammation of, 405 
malformations, 402 
operations on, 405 
cholecystectomy, 406 
cholecystenterostomy, 406 
cholecystotomy, 405 
indications for, 405 
on ducts, 406 
rupture of, 341 
stones in, 402 
treatment, 405 
surgery of, 402 
Gall-duct, common, stricture of, 406 
Gall-stones, 402 
treatment for, 405 
Gangrene of lung, 280 
of scalp, 17 
Gasserian ganglion, removal of, 122 
Gastric adhesions, painful, operations for 
relief of, 355 
fistula1, 347 
treatment, 347 
Gastro-anastoinosis, 355 
Gastro-enterostomy, 354 
Gastrorrhaphy, 355 
Gastrostomy, 350 
for malignant disease of oesophagus, 310 
WitzePs method, 351 
Gastrotomy, 350 
preliminary to Loreta’s operation, 352 
Genito-urinary tract, surgery of, 457 
bladder, 487 
kidney, pelvis, and ureter, 495 
penis and urethra, 470 
prostate and appendages, 479 
spermatic cord, 508 
testicle and epididymis, 506 
infections of, 468 
injuries of, 462 
bladder, 464 
kidney, 466 
penis, 462 
urethra, 463 
malformations of bladder, 460 
kidney and ureter, 461 
penis, 457 
prepuce, 457 
testicle and vas deferens, 461 
urethra, 457 
operations on, 511 
Genu valgum, 648 
treatment, 649 
varum, 645 
treatment, 646 
Gingivitis, 327 
Glands of Bartholin, abscess of, 524 
cysts of, 524 
Glaucoma, 729 
treatment, 730 
Glossitis, acute parenchymatous, 320 
Gluteal artery, ligation of, 149 
hernia, 417 778 
INDEX. 
Goitre, 244 
aberrant, 245 
exophthalmic, 245 
inflammation of, 246 
treatment, 245 
Gonorrhoea of kidney, 495 
of rectum, 448 
of ureter, 495 
Gonorrhoeal peritonitis, 384 
Graefe’s operation for entropion, 707 
Grenouillettes, suprahyoid, 746 
Gritti’s osteoplastic amputation through 
femoral condyles, 618 
Guerin’s method of repair of elliptical de- 
fects, 698 
Gunshot fractures of skull, 29 
wounds of abdominal viscera: 
of bladder, 344 
of diaphragm, 298 
of kidney, 344 
of liver, 344 
of mediastinum, 267 
of pancreas, 344 
penetrating, of abdomen, 342, 344 
of spine, 92 
of spleen, 344 
symptoms, 343 
of thorax, 264 
non-penetrating, 264 
penetrating, 264 
treatment, 343 
of ureters, 344 
Guyon’s supramalleolar amputation of leg, 
613 
HjEMATOMA of abdominal wall, 339 
Hsemothorax, 267, 286 
Hallux valgus, 671 
treatment, 672 
varus, 672 
Halsted’s method for radical cure of inguinal 
hernia in male, 424 
of suture of intestine, 370 
operation for mammary cancer, 586 
prognosis after, 587 
Hamilton’s method of skin transplantation, 
687 
Hand, amputation of, 601 
Hand, club-, 656 
Hare-lip, 220 
operation for its relief, 225, 226, 227 
Hartley-Krause’s operation for removal of 
Gasserian ganglion, 122 
Head, injuries and diseases of, 17 
injuries, mental and psychic disturbances 
following treatment, 71 
injuries of, previous and during birth, 24 
caput succedaneum, 24 
cephalhsematoma neonatorum, 24 
depression of skull, 25 
fractures, 24 
Heart and pericardium, malformations of, 
126 
surgical diseases and injuries of, 126 
wounds and injuries of, 127 
manner of producing death in, 128 
paracentesis of, 131 
Heart, rupture of, 271 
wounds and injuries of, 270, 271 
treatment of, 129 
suture of heart muscle, 129, 130 
Hemorrhage of abdominal wall, 340 
treatment of, 342 
in cancer of stomach, 348 
from carotid, intracranial, 46 
control of, in operations on head, 73, 77 
differential diagnosis between pulmonary 
and arterial, 265 
following extraction of teeth, 328 
in gastric ulcer, 345, 346 
intracranial, 45 
intraventricular, 47 
from kidney, 505 
from longitudinal sinus, 45 
from middle meningeal artery, 46 
oesophageal, 309 
pancreatic, 395 
peritoneal, differential diagnosis from 
peritonitis, 387 
retroperitoneal, 342 
spinal, 94 
subdural, 47 
Hemorrhoids, 433 
external, 433 
internal, 434 
treatment, palliative, 434 
carbolic-acid injection, 434 
radical, 434 
after-treatment, 436 
Allingham’s operation, 435 
American operation, 435 
clamp and cautery, 435 
technique, 435 
Smith’s, 435 
Whitehead’s operation, 435 
Hepatic duct, operation on, 406 
Hermaphrodism, 459 
Hernia, 407 
of bladder diverticula. 419 
treatment, 419 
causes of, 407 
cerebri, 49 
classification, 407 
contents of, 408, 409 
coverings of, 408 
diaphragmatic, 417 
acquired, 417 
congenital, 417 
f femoral, 415 
treatment, Bassini’s method, 429 
formation of, 408 
gluteal, 417 
incarcerated, 409 
treatment, 420 
inflamed, 410 
treatment, 420 
inguinal, 412 
diagnosis, 415 
differential, 415 
' direct, 415 
indirect, 413 
acquired, 414 
congenital, 413 
coverings of, 414 INDEX. 
779 
Hernia, inguinal, indirect, funicular, 413 
infantile encysted, 413 
irreducible, 409 
treatment, 420 
ischiatic, 417 
into labium, 525 
lumbar, 417 
obstructed, 409 
treatment, 420 
obturator, 417 
perineal, 417 
properitoneal, 418 
rectal, 438 
reducible, 404 
reduction of, 421 
retroperitoneal, 418 
causing intestinal obstruction, 356 
sac, 408 
sacro-rectal, 418 
strangulated, 410 
treatment, 421 
taxis in, 421 
dangers of, 421 
treatment, operative, for radical cure, 423 
of femoral, Bassini’s method, 429 
of inguinal, in female, 429 
of umbilical, 430 
of ventral, 430 
Bassini’s method, 424 
early operations, 424 
Halsted’s method, 425 
recurrence after, causes, 428 
for strangulated, 421 
choice of operations, 422 
inguinal and femoral, 421 
obstruction persisting after opera- 
tion, 423 
umbilical, 421 
viability of bowel in, 422 
palliative, in inflamed hernia, 420 
in irreducible hernia, 420 
in obstructed hernia, 420 
truss, 420 
contraindications to, 420 
umbilical, 415 
acquired, 416 
congenital, 415 
treatment, 416 
infantile, 416 
ventral, 416 
from contusions, 339 
epigastric, 416 
following laparotomy and other wounds, 
417 
as a result of congenital failure of de- 
velopment, 417 
of vermiform appendix, 419 
Herniotomy, 421 
bowel integrity in, 422 
dangers during performance, 421, 422 
intestinal obstruction persisting after, 423 
methods of completion, 422 
Herpes, differential diagnosis from chan- 
croid, 520 
of penis, 470 
zoster ophthalmicus, 717 
Heteroplasty, 686 
Hip abscess, treatment, non-operative, 681 
disease, treatment of, ambulatory, 676 
fixation, 676 
protection, 676 
traction, 677 
Thomas’s splint, 677 
Phelps’, 680 
mechanical, 677 
recumbency, 674 
dislocation of, congenital, 640 
treatment, 642 
operative, 643 
Hip-joint, disarticulation of, 620 
prophylactic hsemostasis, 621 
Wyetli’s method, 621 
technique of, 622 
Hofi'a’s operation for congenital dislocation 
of hip, 643 
| Horsley’s method of controlling hemorrhage 
in bone, 77 
j Hordeolum, 702 
Hydatid cyst of kidney, 503 
of liver, 401 
of lung, 282 
| Hydrencephaloceles, 64 
j Hydrocele, 510 
of cord, 508 
of neck, 236 
treatment, 510 
by injection, 511 
radical, 511 
Hydrocephalus, 64 
meningeus or externus, 64 
treatment, 65 
ventriculorum or internus, 64 
treatment, 65 
Hydrogen gas as an aid in diagnosis of rup- 
ture of bladder, 465 
Hydronephrosis, 500 
treatment, 502 
Hydrothorax, 282 
treatment of, 283-285 
Hyoid bone, dislocation of, 240 
fracture of, 240 
Hypertrophy, idiopathic, of spleen, 398 
of prostate, 481 
treatment, 482 
local, 482 
operative, castration, 485 
ligature of vas deferens, 485 
opening bladder, 484 
prostatectomy, 485 
Hypospadias, 458 
situations, 458, 459 
| Hysterectomy, 546 
abdominal, 547 
technique of, 548 
cuff operation, 550 
dangers of, 547 
technique of, 546 
vaginal, 546 
TNDIAN method of rhinoplasty, 218 
| J. Infantile encysted hernia, 413 
Infection, paths of, within cranium, 51 
Inferior dental nerve, operations on, 122 
) Inguinal hernia, 412 
ischiatic, 417 780 
INDEX. 
Inguinal hernia, direct, 415 
indirect, 413 
radical cure for, Bassini’s method, 424 
Ilalsted’s method, 425 
Iliac artery, ligation of common, 148 
external, 150 
internal, 149 
Abernethy’s operation, 151 
Astley Cooper’s operation, 150 
Ileus paralyticus, 368 
Imbecility, surgical treatment of, 67 
Impotence, 515 
incipient, cause of, 480 
treatment, 516 
Innominate artery, ligation of, 135 
Insemination, disorders of, 515 
Intercostal artery, wounds of, 268 
neuralgia, 272 
Interscapulo-thoracic amputation, 606 
Intestinal anastomosis, methods, 369 
extravasation, 344 
obstruction persisting after herniotomy, 
423 
Intestine, rupture of, 340 
treatment, 340 
Intestines, obstruction of, acute, 356 
causes, 356 
from appendicitis, 360 
from intussusception, 358 
treatment, 359 
operative, 360 
from volvulus, 360 
treatment, 361 
treatment, 363 
operative, 363 
palliative, 363 
chronic, 364 
causes, 364 
carcinoma, 364 
treatment, 366 
fecal impaction, 367 
sarcoma, 367 
stenoses, 367 
paralysis, 368 
operations on, 371 
anastomosis, 373 
enteroplasty, 375 
enterostomy, 374 
jejunostomy, 375 
resection, 371 
surgery of, 356 
suture of, 369 
methods, 369 
Cushing’s, 370 
Czerny-Lembert, 369 
Halsted’s, 370 
Lembert, 369 
Murphy button, 370 
Senn’s plates, 370 
tumors of, 364-367 
wounds of, 371 
Intracranial defective development, 67 
operation for, 68 
suppurations, treatment of, 60, 61 
tumors, 71 
operation for, 72 
vessels and sinuses, 45 
Intracranial vessels and sinuses, injuries of, 
45 
aneurisms following, 47 
carotid, 46 
middle meningeal artery, 46 
treatment, 46 
sources of, 45 
subdural hemorrhages, 47 
traumatic ventricular hemorrhage, 
47 
Intramammary abscess, 568 
Intraocular tumors, 734 
choroid, 735 
ciliary body, 735 
iris, 734 
retina, 736 
Intraspinal division of posterior nerve- 
roots, 124 
Intubation of larynx, 171 
accidents and dangers from, 174 
feeding after, 174 
indications for, 172 
instruments required, 171 
method of performance, 172 
withdrawal of tube, 173 
Intussusception, 358 
treatment, 359 
of bowel. 440 
treatment, 442 
Invagination of bowel, 440 
Iris, inflammation of, 727 
gummatous, 728 
plastic, 728 
purulent, 728 
treatment, 729 
Iritis, 727 
Ischiatic hernia, 417 
Ischio-rectal abscess, 442 
JACKSONIAN epilepsy, surgical treat- 
ment for, 69 
Jaesche-Arlt operation for entropion, 707 
Jaundice in gall-stones, 405 
Jaws, actinomycosis of, 329 
ankylosis of, 329, 330 
inflammation of, acute, 327 
gingivitis, 327 
periostitis, osteomyelitis, 328 
secondary, lesions from, 329 
ligaments of, relaxation of, 330 
necrosis of, 328 
treatment, 329 
pyorrhoea alveolaris, 327 
resection of lower, technique of, 330 
upper, technique of, Fergusson’s meth- 
od, 332 
osteo-plastic, Langenbeck’s method, 
333 
syphilis of, 329 
tuberculosis of, 329 
tumors of, 330 
Jaws and teeth, anatomy of, 325 
abscess of, 327 
diseases of, 326 
injuries of, 326 
malformations, congenital of, 326 
surgical diseases and injuries of, 325 INDEX. 
781 
Jejunostomy, 375 
Joint disease, mechanical treatment of, 674 
Jugular vein, wound of, 250, 251 
JBEETLEY’S dermatoplastic amputation 
V of foot, 615 
Keratoconus, 726 
Keratomyxis, 733 
Kidney, congenital malformations of, 461 
cysts of, 500 
conglomerate or cystic degeneration, 
502 
hydatid, 503 
hydronephrosis, 500 
treatment, 502 
diseases of, 495 
calculus of, 498 
treatment, 500 
colic, 504 
gonorrhoeal infection, 495 
treatment, 495 
pus in (pyonephrosis), 497 
treatment, 497 
septic infection (pyelitis), 495 
treatment, 495, 496 
surgical kidney, 497 
tubercular infection, 498 
treatment, 498 
hemorrhage from, 505 
inflammation about (perinephritis), 504 
treatment, 505 
injuries to, 466 
open wounds, symptoms of, 466 
subcutaneous, symptoms, 467 
movable and floating, 503 
treatment, 504 
pain in (nephralgia), 505 
tumors of, 503 
treatment, 503 
Knapp’s operation of blepharoplasty, 712 
Knee, disarticulation of, 616 
advantages over amputation in continu- 
ity, 616 
hooded method of Stephen Smith, 617 
Knee-joint disease, treatment, 681 
mechanical, 682 
operative, 684 
Knock-knee, 648 
Kocher’s method of removal of tongue, 324 
Kyphosis, due to rickets, 258 
IACHRYMAL apparatus, diseases of, 722 
J cystoid disease of gland, 723 
dacryo-cystitis, 724 
treatment, 725 
dacryo-adenitis, 722 
malformations, 723 
tumors of, 723 
“La lumiere noire,” 767 
Laminectomy, 89, 112 
indications for, 112 
in Pott’s disease, 114 
Langenbeck’s method of excision of tongue, 
325 
of osteoplastic resection of upper jaw, 
333 
Laparo-splenotomy, 398 
Laparotomy followed by hernia, 417 
Laryngectomy, 179 
Laryngitis, oedematous, 158 
Laryngoceles, 235 
Laryngotomv, 169 
Laryngo-tracheal abscess, 241 
Larynx, burns of, 160 
treatment, 161 
fistula of, 165 
foreign bodies in, 161 
treatment, 162 
fracture of, 159, 240 
treatment, 160 
injuries of, 159 
contusion, 159 
wounds, 259 
intubation of, 171 
accidents and dangers of, 174 
feeding after, 174 
indications for, 172 
instruments required, 171 
method of performing, 172 
time for removal of tube, 173 
withdrawal of tube, 173 
oedema of, 158 
perichondritis of, 163 
stricture of, 164 
treatment, 164 
tumors of, 175 
malignant, 177 
treatment, 176 
Lateral curvature of spine, 110 
Leg, amputation of, 612 
atypical methods, 615 
Bruns’ method, 615 
at point of election, 613 
supramalleolar (Guyon’s), 613 
Lembert’s method of intestinal suture, 369 
Lens, opacity of, 732 
Leontiasis, 23 
Leptomeningitis, 58, 67 
Ligation of arteries, 133 
aorta, abdominal, 148 
axillary, 143 
brachial, at middle of arm, 144 
at bend of elbow, 144 
carotid, common, 136 
external, 137 
internal, 140 
causes for, 133 
dorsalis pedis, 157 
facial, 139 
femoral, 151 
common, 151 
superficial, at apex of Scarpa’s tri- 
angle, 152 
in Hunter’s canal, 153 
gluteal, 149 
iliac, common, 148 
internal, 149 
external, 150 
inferior thyroid, 140 
innominate, 135 
lingual at its first part, 138 
occipital, 140 
palmar arch, 148 
peroneal, 155 782 
INDEX. 
Ligation of arteries, popliteal, 153 
pudic, internal, 149 
radial, 145 
sciatic, 149 
subclavian, 141 
superior thyroid, 138 
technique of, 134 
temporal, 140 
tibial, anterior, 155 
posterior, 153 
behind malleolus, 155 
ulnar, 146 
vertebral, 140 
Lingual artery, ligation of, 138 
nerve, operations on, 123 
Lips, epithelioma of, 317 
treatment of, 317, 318 
fissures of, 317 
congenital, 219, 220 
hare-lip, 220 
injuries to, 222-228 
macrocheilia, 220, 318 
malformations, acquired, 221 
congenital, 219 
operations on, 225 
surgery of, 219, 223, 317 
syphilis of, 317 
tuberculosis of, 317 
tumors of, 224, 318 
ulcers of, 223 
epithelioma of, 225, 226, 227 
Lisfranc’s amputation of foot, 608 
Litholapaxy, 490 
complications following, 492 
dangers of, 491 
technique of, 491 
Lithotomy, 490 
lateral, for urinary calculi, 490 
median, 490, 512 
suprapubic, 490 
indications for, 491 
Liver, abscess of, 399 
due to amoeba coli, 399 
treatment, 400 
cysts of, hydatid, 401 
serous and dermoid, 402 
treatment, 401 
displacement of, 399 
injuries of, 341 
rupture of, 341 
surgery of, 341 
tumors of, 402 
wounds of, 341 
Lorenz’s method of operations for congeni- 
tal dislocation of hip, 643 
Loreta’s operation for pelvic stricture, 349, 
352 
Ludwig’s angina, 247, 320 
Lumbar hernia, 417 
puncture for hydrocephalus, 66 
for pressure cerebro-spinal fluid, 115 
Lung, abscess of, 279 
treatment, 279, 280 
tubei’culous, 280 
diagnosis of malignant disease of, 296 
gangrene of, 280 
treatment, 282 
Lung, hydatid cyst of, 282 
rupture of, 268 
surgery of, 268 
tumors of, 297 
Lungs, surgical anatomy of, 278 
Lymphatics of breast, 564 
McBURNEY’S method of radical cure of 
hernia, 423 
operation for removal of appendix in in- 
terval, 381 
Macewen’s osteotomy for genu valgum, 650 
suprameatal triangle, 61 
Macrocheilia, 220, 318 
Macroglossia, 322 
Macrostoma, 220 
Malgaigne’s operation for hare-lip, 225 
Malleus, removal of, 760 
Malum coxae senile, 681 
Mammary abscess, superficial, 568 
artery, internal, wounds of, 269 
secondary hemorrhages from, 269 
treatment of, 270 
Mastitis, 567 
acute, 567 
chronic, 569 
differential diagnosis from carcinoma, 
569 
treatment, 570 
Mastodynia, 573 
treatment, 573 
Mastoid, operation in, 760 
technique of, 762 
disease, 760 
Maxilla, inferior, l'esection of, 330 
superior, resection of, 331 
Maxillary sinus, disease of, 198 
Meckel’s diverticulum causing intestinal ob- 
struction, 356, 358 
ganglion, removal of, 122 
Median nerve, injury to, 119 
operations on, 124 
Mediastinitis, 277 
Mediastinum, gunshot wound of, 267 
inflammation of, 277 
injuries of, 277 
contusions, 277 
wounds, 277 
surgery of, 267, 295 
surgical anatomy of, 276 
tumors of, 295 
differential diagnosis, 296 
sarcoma, 295 
treatment, 296 
Membrana tympani, operation upon, 757 
for acute inflammation of middle ear, 
758 
for removal of membrana, malleus, 
and incus, 758 
technique of, 757 
rupture of, 756 
Meningeal artery, hemorrhage from, 46 
treatment, 46 
Meningitis, 57, 66 
classification of, 57, 66 
leptomeningitis, 58, 67 
symptoms, 58, 69 INDEX, 
783 
Meningitis, leptomeningitis, differential [ 
diagnosis, 59 
treatment, 59, 67 
pachymeningitis externa, 57, 66 
treatment, 61, 67 
haemorrhagiea, 58, 66 
interna, 58, 66 
treatment, 61, 67 
Meningocele, 62 
treatment, 64 
Mesentery, cysts of, 393 
diseases of, 392 
embolism and thrombosis of, 392 
tuberculosis of, 392 
Metatarsalgia, 672 
treatment, 672 
Microstoma, 220 
Microtia, 750 
Mikulicz’s operation for rectal prolapse, 440 
Milking of seminal vesicles, 480 
Mortality after amputations, 623 
Morton’s painful affection of foot, 672 
Mouth, acquired defects, 316 
anatomy of, 311 
bacteria of, 312 
causing dental caries, 327 
congenital defects of, 313 
cleft-palate, 313 
methods of closing, 314 
obturators, 316 
technique of uranoplasty, 314 
after-treatment of, 315 
time of operation, 314 
embryology of, 311 
gags, 312, 313 
inflammatory processes of, acute, 316 
stomatitis catarrhalis, 316 
ulcerosa, 316 
noma, 317 
injuries to, 312 
surgical diseases and injuries of, 311 
Movable kidney, 503 
treatment, 504 
Murphy’s button, 370 
Muscle, levator palpebrse superioris, paral- 
ysis of, 705 
orbicularis, paralysis of, 705 
spasm of, 704 
pectoralis major, congenital absence of, 262 
sterno-mastoid, hsematoma in new-born, 
252 
inflammation of its sheath, 253 
rupture of, 251 
spasm of, wry neck, 252 
syphilitic induration of, 252 
wounds of, 250 
Muscular spasm, 120 
treatment of, 120 
Musculo-spiral nerve, injury of, 119 
operations on, 124 
Myo-flbromata of uterus, 542 
treatment, 545 
Myomectomy, abdominal, 547 
NARES, posterior, plugging, 195 
Nasal cavities, tumors of, 191 
septum, dislocations of, 200 
Nasal septum, fracture of, 199 
injuries of, 199 
operations on, 200 
Nasopharyngeal tumors, 186, 188 
treatment, 188 
Neck, abscess of, 233 
treatment of, 233 
congenital fistulse of, 231, 234, 238, 246, 
250 
contusions of, 231 
cysts of, 236, 241 
dermoid, 237 
hydrocele, 236 
sanguineous, 237 
inflammations of, 233 
infrahyoid region, 238 
injury by hanging, 238 
malformations, congenital, 238 
wounds of, suicidal, 239 
penetrating, above larynx, 239 
lateral region, 250 
affections of sterno-mastoid muscle, 
250, 251, 252, 253 
malformations of, acquired, 250 
congenital, 238 
wounds of, 250, 251 
nerves of, injury to, 251 
parotid region, 247 
hvpersemia of, 248 
inflammation of, 248 
injuries, 247 
malformations, 247 
operations on, 249 
posterior region, 256 
aneurism in, 256 
rupture of muscles in, 256 
wounds of, 256 
submental region, 246 
cysts of, 246 
inflammation of, 247 
wounds of, 246 
supraclavicular region, 254 
injuries to nerves in, 255 
malformations, 254 
neuroses, 255 
wounds of, 254, 255 
surgery of, 131 
tumors of, 235, 238, 241 
aeroceles, 235 
pneumatocele, 235 
wounds of, 232 
air-embolism in, 232 
Necrosis of cranial bones, 24 
of jaws, 328 
treatment, 329 
Nelaton’s operation for hare-lip, 226 
Nephralgia, 505 
Nephrectomy, 514 
through abdomen, 514 
Nephrotomy, 502, 513 
Nerves, contusions of, 118 
dislocation of, 125 
eighth, injury of, 51 
facial, injury of, 119 
fifth, 51 
oculomotor, 51 
olfactory, 50 784 
INDEX. 
Nerves, optic, injury of, 50 
seventh, injury of, 51 
median, injury of, 119 
musculo-spiral, injury of, 119 
operations on, 121 
brachial plexus, 124 
deep posterior cervical plexus, 124 
fifth nerve, 122 
inferior dental, 122 
intraspinal division of posterior nerve- 
roots, 124 
lingual, 123 
median, 124 
musculo-spiral, 124 
nerve-grafting, 121 
nerve-stretching, 121 
nerve-suture, 121 
neuroplastic surgery, 121 
radial, 124 
for removal of Gasserian ganglion, 122 
of Meckel’s ganglion, 122 
sciatic, 124 
seventh, 123 
spinal accessory, 123 
supraorbital nerve, 122 
tibia!, 124 
ulnar, 124 
optic, tumors of, 746 
phrenic, injury of, 120, 251 
pneumogastric, injury of, 119, 251 
radial, injury of, 119 
sciatic, injury of, 119 
surgery of, 118 
tumors of, 124 
ulnar, injury of, 119 
wounds and injuries of, 118 
Neudorfer’s method of amputation of thigh, 
620 
Neuralgia, 120 
intercostal, 272 
of mammae, 573 
operations on fifth nerve for relief of, 214 
treatment of, 120 
Neuroplastic surgery, 121 
Nipple and areola, diseases of, 565 
fissure of, 566 
inflammation of, 565 
multiple, 564 
Paget’s disease of, 565 
retraction of, in cancer, 579 
Nocturnal emissions, 518 
Noma, 317 
Nose, accessory sinuses, diseases of, 196 
deformities of, 198 
deviations of, 216 
dislocations of, 217 
fistulse of, 216 
foreign bodies in, 192 
treatment, 193 
fracture of, 199, 217 
treatment, 199 
injuries and diseases of, 216 
insects in, 193 
treatment, 194 
malformations of, acquired, 216 
congenital, 216 
operations on, 200, 218 
Nose, surgery of, 216 
tumors and polypi of, 191 
Nucha, rupture of its muscles, 256 
: Nystagmus, 748 
Obstruction of intestine, 356 
acute, 356 
causes, 356 
appendicitis, 360 
intussusception, 358 
volvulus, 360 
diagnosis, 362 
symptoms in general, 361 
treatment, 363 
chronic, 364 
causes, 364 
carcinoma, 364 
fecal impaction, 367 
paralysis, 368 
sarcoma, 367 
stenosis, 367 
Obturator for closure of cleft palate, 314, 316 
hernia, 417 
Occipital artery, ligation of, 140 
Oculomotor nerve, injury of, 51 
Odontoma, 326, 330 
O’Dwyer’s intubation instruments, 171 
CEdema of larynx, 158 
(Esophageal bougies, 308 
forceps, 305, 306 
(Esophagectomy, 310 
j (Esophagismus, 306 
| (Esophagotomy, external, 306 
internal, 306 
: (Esophagus, diverticula of, 302 
treatment, 302 
foreign bodies in, 304 
treatment, 305 
by external cesophagotomy, 306 
hemorrhage from, 309 
malformations of, 301 
malignant disease of, 309 
epithelioma, 309 
treatment, 310 
cesophagotomy, 306 
paralysis, 309 
perforation of, 304 
rupture of, 303 
spasm of, 306 
treatment, 307 
stricture of, 307 
treatment by retrograde dilatation, 308 
by sounds, 308 
surgical anatomy of, 301 
injuries and diseases of, 301 
wounds of, 240, 303 
Ogston’s osteotomy for genu valgum, 650 
Olfactory nerve, injury of, 50 
Omentum, abscess of, 391 
new growths of, 391 
cysts, 391 
solid tumors, 391 
treatment, 392 
surgery of, 391 
Oophorectomy for uterine fibroids, 550 
Ophthalmia neonatorum, 713 
purulent, 712 INDEX. 
785 
Ophthalmia, purulent, treatment, 713 
sympathetic, 730 
treatment, 732 
Optic nerve, injury of, 50 
Orbit, enucleation of, 739 
inflammation of, 739 
treatment, 739 
injuries of, 736 
foreign bodies in, 738 
fracture of, 737 
treatment, 738 
hemorrhage in, 738 
protrusion of, 740 
tumors of, 742 
arising in bony wall, 745 
treatment, 746 
in cellular tissues of cysts, 744 
Orcliidectomy for prostatic enlargement, 
485 
Orchitis, 507 
treatment, 507 
Osteoclasis, osteoclasts, 647 
Osteomyelitis of cranial bones, 23 
Osteoplastic resection, 77 
of spine, 113 
of upper jaw, 333 
tarsectomy, Link’s, 612 
Osteotomy, 648, 650 
for bow-legs, 648 
for knock-knee, 650 
Othseraatoma, 751 
Ovariectomy for fibroids of uterus, 550 
Ovary, cysts of, 552 
complications of, 554 
contents of, 553 
dermoid, 553 
differential diagnosis of, 555 
examination for, 554 
facies ovariana in, 554 
secondary changes in, 553 
treatment, 555 
surgery of, 522 
PACI’S method of treatment for con- 
genital dislocation of hip, 643 
Pachydermic cachexia, 243 
Pachymeningitis externa, 57, 66 
hsemorrhagica, 58, 66 
interna, 58, 66 
Paget’s disease of nipple, 565 
Pain in Pott’s disease, 98 
Palate, hard, cleft of, Brophy’s method of 
closure, 333 
soft, cleft of, Brophy’s method of closure, 
336 
syphilis of, 181 
Palmar arch, ligation of, 148 
Pancreas, calculi, 395 
cysts of, 395 
treatment, 396 
gangrene of, 395 
hemorrhage of, 395 
inflammation of, 393 
acute hemorrhagic, 393 
suppurative, 394 
treatment, 394 
chronic, 395 
Pancreas, rupture of, 341 
sclerosis of, 395 
surgery of, 393 
tumors of, 396 
carcinoma, 396 
treatment, 396 
Pancreatitis, acute hemorrhagic, 393 
gangrenous, 395 
suppurative, 394 
treatment, 394 
chronic, 395 
Panophthalmitis, 733 
treatment, 734 
Paralysis of external ocular muscles, 748 
infantile, treatment of, 669 
spastic, 666 
treatment, 667 
in spinal myelitis, 88 
Paralytic deformities of feet and legs, 669 
treatment, 670, 671 
Parametrium, acute inflammatory processes 
of, 556 
abscess of, 556 
treatment, 557 
Parotid, accessory, tumors of, 230 
gland, fistulse of, 248 
hypersemia of, 248 
inflammation of, 248 
malformations of, 247 
operations on, 249 
surgery of, 247 
tumors of, 249 
wounds and injuries to, 247 
Patient, examination of, in genito-urinary 
disease, 469 
; Pemphigus of conjunctiva, 718 
Penis, congenital malformations of, 457 
absence, 457 
misplacement, 457 
multiple, 457 
rudimentary, 457 
diseases of, 470 
cavernitis, 471 
epithelioma, 471 
treatment, 471 
gummata, 471 
herpes, 470 
treatment, 471 
scabies, 471 
warts, 471 
j injuries of, 462 
dangers of urinary extravasation in, 
462 
dislocation, 463 
fracture, 462 
treatment, 463 
strangulation, 462 
Pericarditis, surgical treatment of, 131-133 
Pericardium, drainage of, 133 
malformations of, 126 
paracentesis of, 131 
surgical injuries and diseases of, 126, 270 
suture of, 129, 130 
wounds and injuries of, 127, 270 
Pericystitis, 494 
Perimetritis, 557 
treatment, 558 786 
INDEX 
Perimetrium, inflammation of, 557 
treatment, 558 
Perineal hernia, 417 
section, 512 
Perineorrhaphy, 528 
for complete lacerations, 534 
Emmet’s operation, 535 
Simon’s, 534 
Tait’s, 535 
for incomplete lacerations, 528 
Doleris’, 530 
Duke’s, 531 
Emmet’s, 529 
Tait’s, 530 
Perinephritis, 504 
course and symptoms, 504 
treatment, 505 
Perineum, 526 
anatomy and function of, 526 
lacerations of, 526 
complete, treatment, 534 
after-treatment, 536 
Emmet’s operation, 535 
Simon’s, 534 
Tait’s, 535 
incomplete, treatment, 528 
Doleris’ operation, 530 
Duke’s, 531 
Emmet’s, 529 
Tait’s, 530 
symptoms, 526 
surgery of, 526 
Periostitis of cranial bones, 23 
Peripancreatitis, 394 
Periproctitis, 444 
Perisplenitis, 396 
Peritoneum, adhesions of, 383 
inflammation of, 383 
bacteriology of, 385 
general, 385 
symptoms, 385 
early, in disease, 386 
late, in disease, 386 
local, 384 
treatment, after-, 388 
medical, 387 
surgical, 387 
drainage in, 388 
technique of, 387 
tubercular, 389 
treatment, 389 
surgery of, 383 
Peritonitis, acute, 383 
bacteriology of, 385 
causes, 384 
diagnosis, 387 
general, 385 
symptoms, 385 
early in disease, 386, 
late, 386 
local, 384 
pathological condition found in, 384 
prognosis after operation, 388 
treatment, after-, 388 
medical, 387 
surgical, 387 
gonorrhoeal, 384 
Peritonitis, rheumatic, 384 
syphilitic, 384 
tubercular, 389 
differential diagnosis from cancerous,390 
treatment, 389 
Peroneal artery, ligation of, 155 
Pes cavus, 669 
planus, 658 
treatment, 661 
Pharyngotomy, infrahyoid, 169 
subhyoid, 168 
Pharynx, adenoid growth of, 184 
treatment, 185 
congenital malformations of, 182 
foreign bodies in, 183 
lymphoid hypertrophy at vault, 184 
naso-, tumors of, 186, 188 
surgery of, 182 
wounds of, 240 
Phelps’ hip-joint brace, 680 
Phimosis, 457 
treatment, 511, 512 
Phrenic nerve, injury of, 120 
Pia, tumors of, 117 
Piles, 433 
PirogofF’s amputation of foot, 611 
Plaster jackets, application of, 105-107 
Plastic surgery, 686 
aseptic or antiseptic precautions in, 690 
defects, repai r of, 693 
circular and irregular, 699 
lanceolate, elliptic, and semilunar, 698 
Guerin’s method, 698 
Szymanowsky’s, 698 
"Weber’s, 698 
quadrangular, 695 
Burow’s method, 696 
trapezoid, 697 
Bruns’ and Langenbeck’s method, 
697 
triangular, 693 
Burow’s, 694 
Dieffenbach’s method, 693 
dressings in, 689 
gliding and pediculated flaps, 690 
skin-grafting (Thiersch’s method), 687 
advantages of, 688 
site of graft, 688 
sliding flaps, 693 
sutures, 691 
syphilis, influence upon, 693 
time for, 692 
transplantation (method of Ilamilton- 
Beverdin), 687 
viability of flap, 690, 691 
Pleura, calcification of, 290 
injuries of, 267 
rupture of, 267 
Plicotomy, 757 
Pneumatocele, 18 
of neck, 235 
Pneumocele, 267 
Pneumogastric nerve, injury of, 119 
Pneumotomy, 279, 296 
Polymastia, 564 
Polypi of nasopharynx, 188 
rectal, 437 INDEX. 
787 
Polythelia, 564 
Popliteal artery, ligation of, 153 
Pott’s disease of spine, 94 
diagnosis, 97, 99 
differential, 101 
prognosis in, 101 
symptoms, 96 
abscess, 99 
deformity, 98, 101 
paralysis, 98, 101 
pain, 98, 101 
treatment, 103 
braces, 108 
of complications, 109 
jackets, 105-107 
recumbency, 103 
selection of method, 108 
Powell’s electric saws, 74 
Pregnancy, ectopic, 559 
abdominal, 560 
diagnosis, 561 
rupture, 561 
treatment, 561 
tubal, 560 
tubo-abdominal, 560 
tubo-uterine, 560 
Prepuce, congenital malformations, 457 
phimosis, 457 
Probang, Sayre’s, 306 
Prolapse of rectum, 437 
treatment, 439, 440 
Prolapsus cerebri, 49 
Properitoneal hernia, 418 
Prostate, anatomy of, 479 
diseases of, 479 et seq. 
enlai'gement of, 481 
kinds of, 481 
treatment, 483 
local, 483 
operative, 484 
castration, 485 
by drainage of bladdei', 484 
by ligation of vas, 485 
by prostatectomy, 485 
infections of, 479 
inflammation, acute, 479 
chronic, 479 
treatment, 480 
tuberculosis of, 485 
ti'eatment, 486 
tumors of, 486 
cancer, 486 
treatment, 487 
Prostatectomy, 485 
Prostatitis, acute, 479 
chronic, 479 
treatment, 480 
Prostato-cystitis, 488 
Psoas, conti-action in Pott’s disease, 110 
Psychoses, the, surgical treatment for, 71 
Pterygium, 715 
treatment, 716 
Ptosis, 705 
treatment, 705 
Pudic artery, internal, ligation of, 149 
Pyelitis, 495 
treatment, 496 
Pyelo-nephritis, 495 
treatment, 496 
Pyogenic bacteria in bladder, 487 
Pylorectomy, 353 
and gastro-enterostomv, 354 
Pyloric cancer, 347 
Pyloroplasty, 352 
Pylorus, operations on, incision fox', 350 
pylorectomy, 353 
and gastro-enterostomy, 354 
pyloroplasty, 352 
stricture of, 349 
surgery of, 347 
Pyonephrosis, 497 
treatment, 497 
Pyo-pneumothorax due to ulcer of stomach, 
346 
Pyoi-rhcea alveolai'is, 327 
Pyosalpinx, 559 
symptoms and treatment, 559 
QUINCKE’S lumbar puncture for hydro- 
cephalus, 66 
vertebral puncture, 115 
Radial artery, ligation of, 145 
nerve, operations on, 124 
Radical cure of hei'nia, 
absolute methods, 423 
femoral, Bassini’s method, 429 
inguinal in female, 429 
in male, Bassini’s method, 424 
Halsted’s method, 425 
recurrence after, 428 
umbilical, 430 
ventral, 430 
j Radiography, 764 
| Ramm-White’s operation for enlarged pi’os- 
tate, 485 
i Ranula, 322 
| Rectocele, 538 
| Rectum, abscess around, 442 
in ischio-rectal fossa, 442 
treatment, 443 
congenital defects of, 431 
absence of, 432 
imperforate anus, 432 
diseases of, 431 
hemorrhoids, 433 
external, 433 
internal, 434 
treatment, palliative, 434 
after-, 436 
operative, 434 
Allingham’s, 435 
clamp and cautery, 435 
Smith’s, 435 
Whitehead’s, 435 
extirpation of, 453 
preliminaiy colostomy, 456 
sphincteric control after, 456 
fistula of, 444 
treatment, 445, 446 
tuberculai', 445 
invagination, 440 
chronic, 442 
ilio-csecal, 440 788 
INDEX. 
Rectum, invagination, treatment, 441 
periproctitis, 444 
polypi, 437 
prolapse, 437 
of all coats of bowel, 437 
dangers, 438 
hernia of, 438 
treatment, 439 
Mikulicz’s operation, 440 
of mucous membrane, 437 
treatment, 439 
after-, 439 
Van Buren’s operation, 439 
stricture of, 449 
cancerous, 450 
treatment, 450 
colostomy, 450 
extirpation, 450 
after-treatment, 451 
technique, 451 
causes, 446-449 
congenital, 449 
spasmodic, 450 
ulceration of, 446 
dysenteric, 447 
fissure, 446 
traumatic, 446 
treatment of, 450 
tubercular, 447 
venereal, 448 
Recurrence of hernia after radical cure, 428 
Reid’s base line, topography of, 74 
Regnoli’s method of excision of tongue, 325 
Renal calculi, 498 
colic, 504 
cysts, 503 
hsematuria, 505 
infections, 495 
tumors, 503 ' 
Resection of intestine, 371 
technique of, 372 
of jaw, of lower, 330 
of upper, 330 
osteoplastic method of Langenbeck, 323 
Respiratory organs, surgical diseases and 
injuries of, 158 
tract, penetrating wounds of, 240 
Retention cysts of tongue, 322 
Retromammary abscess, 568 
Retroperitoneal hernia, 418 
causing intestinal obstruction, 356 
Retropharyngeal abscess, 182, 247 
Reverdin’s method of skin transplantation, 
687 
Rheumatoid arthritis of spine, 112 
Rhinoplasty, 218 
Rhinoscleroma, 194 
Richet’s operation of blepharoplasty, 709 
Rickety rosary, 258 
Rizzoli’s osteoclast, 647 
Rolando’s fissure, topography of, 73 
Rontgen rays in detection of bullets in ab- 
domen, 344 
in surgery, application of, 764 
Rose’s method of removing Gasserian gan- 
glion, 214 
Rupture, 407 
SABANEJEFF’S knee amputation, 618 
Sacral cysts, 84 
Sacro-coccygeal tumors, 116 
Sacro-rectal hernia, 418 
Sacrum, operations on, 115 
tumors of, congenital, 116 
Salivary calculi, 247, 249 
passages, foreign bodies in, 246 
surgery of, 246 
Salpingitis, 558 
pathology of, 558 
symptoms, 559 
treatment, 559 
Sayre’s bristle probang, 306 
Scabies of penis, 471 
Scalp, blood-vessels, diseases of, 19 
aneurism of, 19 
carbuncle of, 17 
cellulitis of, 17 
erysipelas of, 17 
gangrene of, 17 
surgical diseases of, 17 
tumors, benign, 19 
congenital, 18 
cysts, 18 
dermoids, 18 
diagnosis of, 18 
gaseous, 17 
pneumatocele, 18 
malignant, 19 
treatment, 19 
vascular, of, 19 
ulceration of, 17 
Sciatic artery, ligation of, 149 
nerve, bloodless stretching of, 121 
injury of, 119 
operations on, 124 
Scoliosis, 110, 258, 629 
braces, 634, 636 
development of muscles, 636 
diagnosis, 632 
etiology, 630 
manipulation and apparatus, 635 
treatment, 111, 634 
Sedillot’s method of excision of tongue, 325 
Semen, involuntary discharge of, 518 
causes, 518 
treatment, 518 
Senn’s bone-plates for intestinal anastomosis, 
370 
method of rectal inflation of gas, 362 
Sepsis of the genito-urinary tract, 469 
Serum, cancer, of Emmerich and Zimmer- 
man, 588 
Seventh nerve, injury of, 51 
operations on, 123 
Shoulder, disarticulation of, 604 
method, modified circular, 605 
Wyeth’s, 605 
Shoulder-joint disease, mechanical treat- 
ment of, 685 
Sialo-ductilitis, 229 
Simon’s operation for complete laceration 
of perineum, 534 
Sinus, coccygeal, 85 
ethmoid, disease of, 198 
frontal, disease of, 197 INDEX. 
789 
Sinus, maxillary, disease of, 198 
phlebitis, 56 
sphenoidal, disease of, 198 
thrombosis, 55 
treatment, 61 
Sinuses accessory to nasal cavities, diseases 
of,'196 
treatment, 197, 198 
frontal, injuries of, 88 
intracranial, injuries of, 45 
Skiagraphy, 768 
application of, in surgery, 768 
fluoroscope in, 765 
manner of taking pictures, 766 
Tesla’s view of rays, 765 
Skull, congenital conditions of, 20 
aplasia cranii, 20 
diseases of, non-inflammatory, 20 
atrophy, 20 
senile, 21 
leontiasis, 23 
rickets, 22 
fractures of, 28 
of base, 34 
treatment, 37 
comminuted, 28 
depressed, 32 
treatment, 33 
fissured, 28 
gunshot, 29 
mechanism of, 30 
injuries of frontal sinuses, 38 
of one table only, 29 
of vertex, 31 
treatment, 32 
necrosis of, 23 
osteomyelitis, 23 
periostitis of, acute, 23 
chronic, 23 
separation of sutures, 38 
surgical anatomy of, 25 
Smith’s operation for hemorrhoids, 435 
Smith’s (Stephen) bilateral solid flap in am- 
putation of thigh, 620 
“hooded” amputation in knee, 617 
Souchon’s intranasal anaesthetic inhaler, 215 
method of guided dilatation for treatment 
of cervical abscess, 233 
Spasm of spinal column, 93 
Spastic paralysis, 666 
Spermatic cord, diseases of, 508 
hydrocele of, 508 
spermatocele, 508 
varicocele, 508 
treatment, 509 
Spermatocele, 508 
Spermato-cystotomy, 515 
Spermatorrhoea, 518 
Spermatozoa, examination of, in sterility, 517 
Sphenoidal sinus, disease of, 198 
Sphincter, technique of stretching, 435 
Spinal accessory nerve, operations on, 123 
cord, tumors of, 117 
curvatures, backward (kyphosis), 98 
forward (lordosis), 111 
lateral (scoliosis), 110 
hemorrhage, 24 
Spine, concussion and contusion of, 94 
coccygeal dimple and sinus, 85 
curvature, lateral, 629 
treatment, manipulation, 635 
by development of muscles, 638 
mechanical, 634, 636 
curvatures of, not due to primary bone 
disease, 110 
dislocation of, 90 
treatment, 91 
fractures of, 85 
differential diagnosis from injuries of 
cord, 87, 88 
treatment of, 89 
non-operative, 90 
operative, 89 
gunshot wounds of, 92 
treatment, 93 
injuries of, 85 
classification of, 85 
fractures, 85 
diagnosis, 86 
differential diagnosis, 87 
and surgical diseases of, 80 
operations on, 112, 113, 114 
coccyx removal of, 115 
for examination of spine, 114 
laminectomy, 112, 113, 114 
puncture of, 115 
sacrum, 115 
wiring spine, 115 
Pott’s disease of, 94 
treatment, 103 
braces, 108 
jackets, 105 
laminectomy, 114 
recumbency, 103, 104, 105 
selection of method, 108 
sacral cysts, 84 
spasm of, 93 
spina bifida, 80 
treatment, 82 
varieties, 81 
syringomyelia, 84 
tuberculosis of, 94 
tumors of, 116 
wounds of, 92 
penetrating, 92 
treatment, 92 
Spleen, abscess of, 396 
treatment, 397 
displacement of, 397 
treatment, 397 
gangrene of, 397 
hypertrophies of, 397 
idiopathic, 398 
new growths of, 398 
treatment, 398 
laparo-splenotomy, 398 
splenectomy, 398 
rupture of, 341 
suppuration of, 396 
surgery of, 396 
Splenectomy, 398 
Spleno-laparotomy, 398 
Splenopexis, 399 
Spondylitis, 94 790 
INDEX. 
Spondylolisthesis, 112 
Squint, 747 
Staphyloma of cornea, 726 
Staphylorrhaphy, 314, 336 
Brophy’s method, 336 
Stenoses of intestine, 367 
Stenson’s duct, inflammation of, 229 
fistula of, 229 
wounds of, 228 
Sterility, 517 
treatment, 517 
Stomach, congenital malformations of, 344 
fistulte of, 347 
foreign bodies in, 349 
gastrotomy for, 350 
operations on, 350 
for adhesions, 355 
gastro-anastomosis, 355 
gastro-enterostomy, 354 
gastrorrhaphy, 355 
gastrostomy, 350 
gastrotomy, 350 
pylorectomy, 353 
and gastro-enterostomy, 354 
pyloroplasty, 352 
rupture of, 340 
stricture of pylorus, 349 
treatment of, 349 
surgery of, 334 
tumors of, 347 
cancer, 347 
differential diagnosis from ulcer, 348 
treatment, 348 
ulcer of, 345 
treatment, 345, 346 
Stomatitis, 316 
catarrhalis, 316 
ulcerosa, 316 
Stomodoeum, 311 
Stone in bladder, 488 
conditions which favor, 489 
treatment, 490 
choice of methods, 490 
litholapaxy, 490, 491 
lithotomy, 490 
in kidney, 498 
treatment, 500 
Strabismus, 747 
Strangulation of gut through foramen of 
Winslow, 356 
Strapping the breasts, 566 
Stricture of oesophagus, 307 
treatment, 308 
of pylorus, 349 
treatment, 349, 352 
rectal, 449 
urethral, 472 
effects on urethra, 473 
impermeable, 476 
treatment, 477 
location of, 473 
organic, 472 
spasmodic, 472 
treatment, 475 
by gradual dilatation, 475 
by perineal section, 476 
by urethrotomy, 475 
Strumitis, 246 
Stump, causes of painful, 596 
Stye, 702 
Subclavian artery, ligation of, 141 
Subdural hemorrhage, 47 
Subluxation of jaw, 330 
Subperiosteal excision of members, 599 
Subphrenic abscess, 274, 346 
following rupture of stomach, 340 
treatment, 276, 347 
Suprameatal triangle of Macewen, 61 
! Supraorbital nerve, operations on, 122 
Suprapubic aspiration for retention of urine, 
484 
cystotomy, 513 
Surgical anatomy of skull, 25 
kidney, 495 
Suture of intestine, 369 
methods, 369 
Cushing’s, 370 
Czerny-Lembert, 369 
Halsted’s, 370 
Lembert, 369 
Murphy button, 370 
Senn’s plates, 370 
Sylvian fissure, topography of, 74 
Symblepharon, 720 
treatment, 720 
Teale’s operation. 721 
Syme’s amputation of foot, 611 
Synsechotomy, 757 
Syphilis of breast, 572 
of jaws, 329 
of lips, 317 
of palate, 316 
of scalp, 18 
of tongue, 321 
Syringomyelia, 84 
Szymanowsky’s method of repair of lanceo- 
lated defects, 698 
qWGLIACOZZIAN method of rhino- 
X plasty, 218 
Tait’s operation for complete laceration of 
perineum, 535 
for incomplete laceration of perineum, 
530 
Talipes equinus, 665 
treatment, 666 
equino-varus, congenital, 650 
pathology, 651 
treatment, 652 
valgus, 669 
varus, 667 
calcaneus, 667 
treatment, 668 
Tarsus of eyelid, amyloid disease of, 703 
Taxis, 420, 421 
Taylor club-foot shoe, 654 
Teale’s operation for symblepharon, 721 
; Teeth, caries of, 326 
treatment, 327 
eruption of, faulty, 326 
extraction of, 328 
gums, disturbance of, in operation for cleft 
palate, 335 
and jaws, abscess of, 327 INDEX. 
791 
Teeth and jaws, anatomy of, 325 
diseases of, 326 
injuries of, 326 
inflammation about, 327 
malformation of, congenital, 326 
surgical diseases of, 326 
tumor of, odontoma, 326 
Temporal artery, ligation of, 140 
Temporo-sphenoidal abscess, 52 
treatment of, 61 
Tendon-grafting, 668 
Testicle, congenital malformations of, 461 
misplacement of, 461 
danger of malignant disease of, 461 
diseases of, 506 
cystic, 507 
orchitis and epididymitis, 507 
treatment, 507 
syphilis, 506 
diagnosis, 506 
tuberculosis, 506 
treatment, 506 
tumors of, 507 
Thiersch’s method of skin-grafting, 688 
Thigh, amputation of, 617 
condylar, 617 
Carden’s transcondylar, 617 
Gritti’s osteoplastic, 618 
shaft and upper portion, 619 
bilateral solid flap, 620 
circular, 619 
Neudorfer’s method, 620 
Thomas’s splint, 677, 682 
Thoracentesis, 282, 284 
Thoracic duct, tumors of, 297 
wounds of, 255, 270 
Thoracoplasty, 288 
Thoracotomy, 286 
for empyema, 288 
point of election for, 287 
technique of, 287 
Thorax, actinomycosis of, 294 
gummata of, 293 
hHemothorax, 286 
hydrothorax, acute, 282 
thoracentesis in, 283 
tuberculosis following, 285 
thoracoplasty, 288 
thoracotomy, 286 
tuberculosis of, 294 
tumors of, 290 
carcinoma, 294 
treatment when involving external 
surface, 294 
chondroma, 291 
fibroma, 291 
lipoma, 290 
neuroma, 292 
osteoma, 293 
sarcoma, 293 
walls of. diseases of, 272 
Thrombosis and embolism of mesentery, 392 
Thyro-glossal duct, embryology of, 311 
Thyroid artery, inferior, ligation of, 140 
superior, ligation of, 138 
body, goitre of, 244 
inflammations of, 243 
Thyroid body, malformations of, congen- 
ital, 242 
acquired, 243 
myxcedema from removal of, 243 
surgery of, 242 
tumors of, 244, 246 
wounds of, 243 
cartilage, fracture of, 240 
Thyroiditis, 233 
Thyrotomy, 169 
Tibial artery, ligation of, anterior, 155 
posterior, 153 
behind malleolus, 155 
nerve, operations on, 124 
Tic douloureux, 207 
Toes, amputation of, 607 
with corresponding metatarsal, 607 
Tongue, actinomycosis of, 321 
cysts, retention, of, 322 
treatment, 322 
embryology of, 319 
enlargement of (macroglossia), 322 
epithelioma of, 322 
treatment, 323 
Billroth’s method, 324 
excision, partial, 323 
Kocher’s method, 324 
Langenbeck’s method, 325 
Regnoli’s operation, 325 
Sedillot’s method, 325 
inflammation of, acute, 320 
Ludwig’s angina, 320 
parenchymatous glossitis, 320 
injuries of, acute, 319 
chronic, 320 
malformations of, 319 
ranula of, 322 
surgical diseases and injuries of, 318 
syphilis of, 321 
tuberculosis of, 321 
tumors of, benign, 322 
malignant, 322 
Tongue-tie, 319 
Tonsillotomy, 189 
Tonsils, foreign bodies in, 190 
hypertrophy of, 188 
treatment, 189 
surgery of, 188 
tumors of, 190 
Torticollis, 252, 626 
acquired, causes, 626 
acute, of the trapezius, 256 
congenital, causes, 626 
sequelae of, 627 
treatment, 253, 628 
Trachea, burns of, 160 
fistula of, 165 
foreign bodies in, 161 
treatment, 162 
rupture of, spontaneous, 241 
subcutaneous, 241 
! surgery of, 159, 179 
tumors of, 179 
wounds of, 159 
Tracheoceles, 235 
Tracheoma, 714 
I Tracheotomy, 165 792 
INDEX. 
Tracheotomy, after-treatment, 168, 169, 
anaesthetic in, 166 
contraindications, 166 
operation, manner of performing it, 166 
tube in, 166 
Traumatic insanity, surgical treatment for, 
71 
Trephining, 74 
technique of, 75 
Trichiasis, 708 
Trusses for hernia, 420 
contraindications for use, 420 
Tubal pregnancy, 560 
Tubercular peritonitis, 389 
ulceration of rectum, 447 
Tuberculosis of ankle, mechanical treat- 
ment of, 684 
of bladder, 494 
of breast, 570 
diagnosis, 571 
differential, 571 
treatment, 571 
of chest-wall, 294 
of elbow, mechanical treatment of, 665 
of epididymis, 506 
of genito-urinary tract, 468 
age of patients, 468 
avenues of infection, 468 
predisposition to, 469 
sites and paths of infection, 468 
of hip, ambulatory treatment of, 676 
mechanical treatment of, 674, 681 
of jaws, 329 
of kidney, 498 
of lip, 317 
of mesentery, 392 
of metatarsus, mechanical treatment of, 
685 
of omentum, 392 
of peritoneum, 389 
of prostate and appendages, 485 
of scalp, 18 
of shoulder, mechanical treatment of, 685 
of spine, 94 
of tongue, 321 
of wrist, mechanical treatment of, 685 
Tubes, Fallopian, inflammation of, 558 
treatment, 559 
Tubo-abdominal pregnancy, 560 
Tubo-uterine pregnancy, 560 
Tumors of auricle, 752 
of bladder, 492 
of breast, 574 
of conjunctiva, 718 
of cornea, 727 
of diaphragm, 300 
of eyelids, 702, 703 
of face, 211, 213 
of intestine, 364-367 
intracranial, 71 
operation for, 72 
control of hemorrhage in, 73 
varieties, 71 
intraocular, 734 
choroid, 735 
ciliary body, 735 
iris, 734 
Tumors, intraocular, of retina, 736 
of jaw, 330 
of kidney, 503 
of lachrymal gland, 723 
of larynx,175 
of lips, 224, 318 
of liver, 402 
of lung, 297 
of mediastinum, 295 
of nasal cavities, 191 
nasopharyngeal, 186 
of neck, 235, 241 
of nerves, 124 
of oesophagus, 309 
of omentum, 391 
of optic nerve, 746 
of orbit, 742 
of pancreas, 396 
of parotid gland, 249 
of pia and arachnoid, 117 
treatment, 118 
of prostate, 486 
of rectum, 437, 450 
sacro-coccygeal, 116 
of sacrum, congenital, 116 
of scalp, 18 
gaseous, 17, 18, 19 
of spinal cord, 117 
of spine, 116 
of spleen, 398 
treatment, 398 
of stomach, 347 
of teeth, 326 
of thorax, 290 
of thyroid body, 244, 246 
of tongue, 321 
of tonsils, 190 
of uvula, 181 
of vulva, 525 
Tympanum, acute inflammation of, 758 
granulation tissue, 759 
polypi, 759 
treatment for, 759 
Typhoid spine, 110 
ulcer, causing perforation, 390 
symptoms and treatment, 391 
ULCER of rectum, 446 
of stomach, 345 
treatment, 345, 346 
typhoid, perforation of, 390 
symptoms and treatment, 391 
Ulceration of rectum, secondary syphilis, 
449 
tubercular, in peritonitis, 389 
Ulnar artery, ligation of, 146 
nerve, injury of, 119 
operations on, 124 
Umbilical hernia, 415 
radical cure of, 430 
Uranoplasty, 315, 333 
after-treatment of, 315 
Brophy’s method, 333 
Ureter, congenital malformations, 461 
valve-like obstruction, 461 
Urethra, congenital malformations of, 457 
absence, 457 INDEX. 
793 
Urethra, congenital malformations of, atre- 
sia, 457 
epispadias, 460 
hypospadias, 458 
treatment, 459 
pouches, 458 
diseases of, 471 
chancres, 472 
polypi, 472 
strictures, 472 
divulsion of, 478 
effect of, on urethra, 473 
impermeable, 476 
treatment, 477 
organic, 472 
calibre of, 473 
location of, 473 
spasmodic, 472 
symptoms, 474 
traumatic, 472, 474 
treatment, 475-478 
after-, 476 
gradual dilatation, 475 
urethotomv, 475 
internal, 475 
external, 476 
ulcers, 471 
urethral fever following instrumen- 
tation, 476 
examination of, 470 
injuries of, 463 
deep, 464 
remote results from, 464 
with perforation, 464 
treatment, 464 
without perforation, 463 
treatment, 464 
Urethral or urinary fever, 478 
Urethrometer, 474 
Urethrotomy, external, 512 
dangers of, 475 
indications for, 475 
internal, dangers of, 475 
Urinary antiseptics, 479 
fever, 478 
treatment, 479 
Urine, danger of extravasation of, 462, 463, 
464 
retention of, in prostatic enlargement, 
482, 484 
treatment, 484 
Uro-genital tract, infections of, 268 
Uterus, the, 538 
cancer of, 550 
treatment, palliative, 551 
radical (hysterectomy), 551 
myo-fibromata of, 542 
secondary changes in, 543 
treatment, curative, 545 
abdominal hysterectomy, 547 
castration, 550 
myomectomy, 547 
for pedunculated fibroma, 545 
for submucous fibroids, 546 
vaginal hysterectomy, 546 
palliative, 545 
prolapse of, 538 
Uterus, prolapse of, treatment, 539 
Alexander’s operation, 539 
perineorrhaphy and colporrhaphy, 
539 
ventro-fixation, 541 
surgery of, 538 
Uvula, malformations of, 180 
new growths of, 181 
VAGINA, malformations of, 522 
atresia, 522 
treatment, 523 
Van Buren’s operation for rectal prolapse, 
439 
Varicocele, 508 
treatment, 509 
amputation of scrotum, 509 
open ligation and excision, 510 
subcutaneous ligation of veins, 509 
Varicosities of rectum, 435 
Vas deferens, ligation of, for prostatic en- 
largement, 485 
Vasectomy for prostatic enlargement, 485 
Vein, jugular, inflammation of, 253 
subclavian, wounds of, 254, 255 
Venereal ulcer, 519 
ulceration of rectum, 448 
warts, 471 
Ventral hernia, 416 
radical cure of, 430 
Ventro-fixation, 541 
Vermiform appendix, diseases of, 375 
hernia of, 419 
inflammation of, acute, 375 
treatment, medical, 378, 380 
surgical, 379 
chronic, 380 
treatment, 381 
removal of, indications for, in period of 
health, 381 
Vertebral artery, ligation of, 140 
caries, 94 
osteomyelitis, acute, 110 
Vicarious menstruation from breasts, 565 
Viscera, injury of, following blows upon ab- 
dominal wall, 339 
Volvulus, 360 
treatment, 361 
Von Grafe’s coin-catcher, 306 
Vulva, abscess in glands of Bartholin, 524 
cysts of glands of Bartholin, 524 
inflammation about, 523 
symptoms and treatment, 523 
oedema of, 523 
surgery of, 523 
tumors of, 525 
WANDERING SPLEEN, 397 
Warts on penis, 471 
Weber’s method of repair of elliptical de- 
fects, 698 
Whitehead’s mouth-gag, 313 
operation for hemorrhoids, 435 
White’s operation for enlarged prostate, 
485 
Wiring spine, 115 
Witzel’s method of gastrostomy, 351 794 
INDEX. 
Worms, round, causing intestinal obstruc- 
tion, 358 
W rist joint disease, mechanical treatment of, 
685 
Wry neck, 252, 624 
Wyeth’s bloodless method of amputation at 
hip-joint, 621 
method for disarticulation of shoulder, 605 
X-RAYS in detection of bullets in abdo- 
men, 344 
in surgery, 763 
Xanthelasma, 703 
, Xerosis conjunctive, 718 
yAWS, 209 GENERAL INDEX. 
ABDOMEN, gunshot wounds of, i. 345 
surgery of, ii. 339 
surgical diagnosis and examination of, i. 
308 
Abscess, atheromatous, i. 554 
bone, i. 664 
classification of, i- 80 
cold, infection of, i. 659 
lumbar, i. 660 
of lung, ii. 279 
manner of formation, i. 79 
palmar, i. 508 
psoas, i. 660 
of rectum, ii. 442 
retropharyngeal, i. 660 
Achondroplasia, i. 673 
Acne, i. 444 
Acromegaly, i. 680 
Acromial process, fracture of, i. 714 
Actinomycosis, i. 156 
Acupressure, i. 260 
Acute intoxications, i. 251 
Adenitis following gonorrhoeal infection, i 
220 
Adenoma, i. 429 
Aeroceles, ii. 235 
Ainhum, i. 104, 105 
Air embolism, i. 38 
Allantoic cysts, i. 392 
Alveolar abscess, ii. 327 
Ambulatory treatment of fracture, i. 747 
Ammonisemia, i. 122 
Amoeba coli, i. 77, 240 
Ampullitis, i. 219 
Amputations, ii. 589 
arm, ii. 604 
elbow, ii. 602 
fingers, ii. 599 
foot, ii. 607 
forearm, ii. 602 
hand, ii. 601 
hip-joint, ii. 620 
interscapulo-thoracic, ii. 606 
knee, ii. 616 
leg, ii. 612 
lower extremity, ii. 606 
Mikulicz’s, i. 645 
shoulder, ii. 604 
thigh, ii. 617 
toes, ii. 607 
upper extremity, ii. 599 
Anaesthesia and anaesthetics, i. 285 
Anastomosis of cranial bones, ii. 20 
Anel’s method in treating aneurism, i. 571 
Aneurism, i. 556 
cirsoid, i. 418 
traumatic, i. 322 
Angeioma, i. 418, 567 
Aniline preparations in cancer, i. 443, 
466 
Ankle, excision of, i. 643 
Ankylosis, i. 624; ii. 673 
Anthrax, i. 151 
Antisepsis, i. 362 
Antiseptic surgery, i. 370 
Antiseptics, toxaemia from use of, i. 253 
Antitoxin of tetanus, i. 144 
Antrum of Highmore, tooth in, i. 279 
Anus, artificial, ii. 368 
imperforate, ii. 432 
Aorta, abdominal, aneurism of, i. 581 
ligation of, ii. 148 
Aplasia cranii, ii. 20 
Apoplexia neonatorum, ii. 47 
Appendectomy, ii. 381 
Appendicitis, acute, ii. 375 
Appendix, vermiform, diseases of, ii. 375 
Archepyon, absence of fever in, i. 117 
Arm, amputation of, ii. 602 
aneurisms of, i. 579 
Arrow-wounds, poisoned, i. 249 
Arterial varix, i. 566 
Arterio-sclerosis (atheroma), i. 554 
Arteries, ligation of, ii. 133 
surgical injuries and diseases of, i. 547 
Arteriotomy, i. 261 
Arthrectomy, i. 629 
Arthritis, i. 593 
Arthrodesis, i. 630 
Artificial respiration, i. 273 
Asepsis, definition of, i. 364 
Aseptic blood-clot in treatment of disease 
of bone, i. 671 
fever in wounds, i. 320, 381 
Aspiration, i. 263 
Astragalus, dislocation of, i. 775 
Atheroma, i. 554 
Atheromatous abscess, i. 554 
Atrophic elongation of bones, i. 679 
Atrophy, classification of, i. 30 
following acute infectious processes in 
bone, i. 657 
Auditory canal, inflammations of, ii. 754 
Auto-infection, i. 109 
Auto-intoxication, i. 109, 111 
Autoplasty, ii. 686 
Avicenna’s method of reducing dislocations- 
of shoulder, i. 760, 761 
795 796 
GENERAL INDEX. 
Axillary artery, aneurism of, i. 578 
ligation of, ii. 143 
Bacillus anthracis, i. 75 
of bubonic plague, i. 76 
coli communis, i. 73, 649 
diphtherise, i. 74 
of glanders, i. 149 
of influenza, i. 76 
leprae, i. 75 
of malignant oedema, i. 75, 155 
mallei, i. 75 
oedematis maligni, i. 75, 155 
pneumoniae Friedliinder, i. 75 
proteus, i. 74 
pyocyaneus, i. 74 
of Rausch brand, i. 76 
of rhinoscleroma, i. 76 
septicaemise haemorrliagicae, i. 76 
tetanus, i. 75, 139 
tuberculosis, i. 75, 160 
typhi abdominalis, i. 74 
Bacteria causing dental caries, ii. 327 
facultative pyogenic, i. 70, 74 
found in appendicitis, ii. 377 
obligate pyogenic, i. 71 
of pus-formation, i. 70 
Bacterial determination as an indication in 
treatment, i. 77 
Balanitis, i. 218 
Bandages, i. 283 
Bandaging, i. 281 
Barbados leg, i. 527 
Beriberi, i. 234 
Bier’s treatment of joint tuberculosis, i. 177 
Bigelow’s rule for reduction of anterior or 
inward dislocations of hip, i. 772 
Billroth’s angeio-neurotic gangrene, i. 106 
Bites, i. 247 
Black leg, i. 156 
Bladder, congenital malformations, ii. 460 
diseases of, ii. 487 
gunshot wounds of, i. 348 
injuries of, ii. 464 
tuberculosis of, i. 174 
Blepharoplasty, ii. 709 
Blisters, rules for application, i. 265 
Blood, abstraction of, by arteriotomy, i. 261 
changes in, in Hodgkin’s disease, 534 
surgical pathology of, i. 32 
transfusion of, i. 270 
Blood-clot, organization of, i. 354 
Blood-vessels, regeneration of, i. 358 
Blue pus, i. 81 
Bone, surgical diseases of, i. 646 
healing by second intention, i. 361 
rachitis, i. 674 
regeneration of, i. 359-361 
strength of, i. 694 
suturing for delayed union, i. 704 
Bones, lesions of, following exanthemata, i. 
239 
Bouchard on auto-intoxication, i. 109, 110 
Bougard’s paste, i. 465 
Bovinine as surgical dressing, i. 98 
Bow-legs, ii. 645 
Brain, abscess, ii. 52 
Brain, injuries of, ii. 38 
Brain-substance, lacerations and injuries of, 
ii. 47 
Brainerd, treatment of delayed union, i. 
704 
Branchial fistula;, ii. 210, 220, 228, 231, 234, 
238, 246, 250, 311 
Breast, carcinoma, i. 434 
surgical diagnosis and examination of, i. 
308 
injuries and diseases of, ii. 563 
Bronchocele, i. 430 
Buck’s extension, i. 734 
Bunions, i. 275, 396, 513; ii. 671 
Burns, i. 479 
Bursae, i. 396, 487 
adventitious, forming bunions, i. 275 
affections of, i. 510 
synovial, i. 396, 510 
tuberculosis of, i. 173 
nACHEXIA STRUMIPRIVA, ii. 243 
\J Calcaneum, fracture of, i. 748 
Calculus in bladder, ii. 488 
Callosities, i. 451 
Callus, formation of, i. 699 
Cancer en cuirasse, i. 433 ; ii. 580 
Cancrum oris, i. 104; ii. 317 
Caput succedaneum, ii. 24 
| Carbuncle, i. 82, 449 
I Carcinoma, i. 433 
differential diagnosis from sarcoma, i. 441 
Cardicentesis, ii. 131 
Caries, i. 666 
dental, ii. 326 
vertebral, ii. 94 
Carotid artery, aneurism of, i. 579 
ligation of, ii. 136 
Carpo-metacarpal dislocation, i. 765 
Carpus, dislocation of, i. 765 
Carrying power, preservation of, in fractures 
of humerus, i. 719, 720 
Cartilage, repair of, i. 356 
semilunar dislocation of, i. 774 
Castration for enlarged prostate, ii. 485 
Cataract, ii. 732 
Catgut, sterilization of, i. 376 
Catheter, catheterization, i. 271 
Cautery, Paquelin’s thermo-, i. 266 
Cellulitis, i. 137 
Cephalalgia, surgical treatment for, ii. 71 
Cephalhsematoma neonatorum, ii. 24 
Cephalocele, ii. 62 
Cerebral membranes, inflammation of, ii. 66 
Cerebro-spinal meningitis, secondary infec- 
tion in, i. 244 
Cervix, laceration of, ii. 541 
surgery of, ii. 541 
Chalazion, ii. 702 
Chancre, i. 187 
Chancroid, ii. 519 
Charbon, i. 151 
Charcot’s disease of joints, i. 606 
Cheeks, surgery of, ii. 228 
Chemotaxis, i. 50, 57 
Chest, injuries of, ii. 262 
lung, diseases of, ii. 278 GENERAL INDEX. 
797 
Chest, surgery of, ii. 257 
injuries and wounds, ii. 264 
surgical examination and diagnosis of, i. 
307 
Chin, malformations of, ii. 227 
Chloroform, i. 290 
Cholecystectomy, ii. 406 
Cholecystcolostomy, ii. 406 
Cholecystenterostomy, ii. 406 
Cholecystotomy, ii. 405 
Cholelithiasis, ii. 402 
Chondroma, i. 412 
Chordee, i. 218 
Chylocele, i. 523 
Chyluria, i. 528 
Circumcision, ii. 511 
Clap threads, i. 223 
Clavicle, dislocation of, i. 754 
fracture, i. 712 
Clavns, i. 275, 451 
Club-foot, ii. 650 
Coagulation-necrosis as a result of bacterial 
activity, i. 78 
Cocaine for local anaesthesia, i. 303 
Coccidia in tumors, i. 389 
Coccygodvnia, ii. 118 
Coccyx, fracture of, i. 728 
removal of, ii. 115 
Cohnheim’s embryonal hypothesis as cause 
of tumors, i. 388 
Coley’s method of inoculation in inoperable 
malignant growths, i. 442 
Collapse, i. 230 
Colles’ fracture, i. 722 
law in syphilis, i. 208 
Coloboma, ii. 219, 702 
Colon bacillus in intestinal toxaemia, i. 113 
Colostomy, ii. 450 
Colporrhaphy, ii. 539 
Comedo, i. 444 
Common duct, stricture of, ii. 404 
Complications of fractures, i. 695 
Compound dislocations, i. 753 
Condyloma, i. 206 
Congenital dislocations, i. 750 
Conjunctiva, diseases of, ii. 712 
Contusions, i. 319 
Coprsemia, i. 113 
Cornea, diseases of, ii. 726 
repair of, i. 356 
Corns, i. 275 
Cornu cutaneum, i. 451 
Coronoid process, fracture of, i. 721 
Corpora oryzoidea, i. 173, 610 
Corrosive sublimate, toxic effect of, i. 254 
Coude catheter, i. 271 
Cough, diagnostic significance of, i. 315 
Counter-irritation, i. 264 
Cowperitis, i. 219 
Cranial bones, inflammation of, ii. 23 
nerves, injuries of, ii. 50 
topography, ii. 73 
Craniectomy, ii. 68 
Craniotabes, i. 675; ii. 22 
Cranium, gunshot wounds of, i. 339 
injuries to the soft parts of, ii. 26 
operations on, ii. 73 
Cranium, septic infections within, ii. 51 
Crepitus in fractures, i. 696 
Crutch paralysis, i. 500 
Cryptorchidism, ii. 461 
Cupping, i. 261 
Cyst, i. 398 
sebaceous, i. 446 
Cystic degenerations, i. 397 
duct, operation, ii. 406 
Cystitis, due to gonorrhoeal infection, i. 220 
ii. 487 
Cystocele, ii. 538 
Cysts, i. 385 
DACRYO-CYSTITIS, ii. 724 
Dactylitis syphilitica, i. 209 
Delayed union, i. 703 
Delirium tremens, i. 251 
Dermatolysis, i. 412 
Dermoids, i. 398 
Diagnostic features of malignant growths, 
i. 440 
Diaphragm, diseases and injuries of, ii. 298 
injury to, ii. 266 
Diaphragmatic hernia, ii. 300, 417 
Diphtheria, secondary infection in, i. 243 
Dislocation, compound, of joints, i. 590 
of humerus, complicating fracture of sur- 
gical neck, i. 717 
Dislocations, i. 750 
special, i. 753 
Dissection wounds, treatment of, i. 136 
Diverticula, i. 395 
Drainage, i. 370, 371 
of bladder, ii. 484 
Dugas’ test for dislocation of shoulder, i. 757 
Dysentery, i. 240 
EAR, surgery of, ii. 749 
Echinococcus in muscles, i. 514 
Ectopic pregnancy, ii. 559 
Ectropion, ii. 708 
Elbow, disarticulation of, ii. 602 
dislocation of, i. 762 
excision of, i. 632 
Electrolysis in nsevi, i. 546 
Elephantiasis, i. 420, 457, 459, 525 
Emboli in arteries, i. 550 
Embolism, i. 37 
fat-, i. 40 
Embryonal hypothesis of Cohnheim as an 
explanation of tumors, i. 388 
Emphysema of chest, ii. 271 
following fractures, i. 705, 711 
Emprosthotonos, i. 141 
Empyema of antrum of Highmore, ii. 329 
i. 86 
Encephalitis, ii. 59 
Endarteritis, i. 552-554 
Endocarditis, secondary infection in, i. 244 
Endocranitis, ii. 57 
Endoscope, i. 226 
Endothelioma, i. 438 
Enterocele, ii. 408 
Enteroplasty, ii. 375 
Entero-sepsis, i. 113 
Enterostomy, ii. 374 798 
GENERAL INDEX. 
Entropion, ii. 706 
Epicanthus, ii. 701 
Epicondyles, fracture of, i. 718 
Epidermization, i. 355 
Epididymis, tuberculosis of, i. 174; ii. 506 
Epididymitis, i. 220 ; ii. 507 
Epiglottis, injuries of, ii. 180 
Epilepsy, surgical treatment for, ii. 69 
Epiphyseal fractures, i. 702 
Epiphysitis, acute, i. 656 
Epiplocele, ii. 408 
Epispadias, ii. 460 
Epistaxis, ii. 194 
Epithelioma, i. 426 
Eruptions due to drugs, i. 118 
Erysipelas, i. 130 
Erysipeloid, i. 137 
Erythema induratum, i. 475 
multiforme, i. 119 
Erythromelalgia, i. 20 
Esthiomene, ii. 488 
Excisions, indications for, i. 629 
special, i. 631 
Exophthalmic goitre, ii. 245 
Exophthalmos, pulsating, ii. 740 
Exostoses, i. 415, 684 
Extra-uterine pregnancy, ii. 569 
Extrophy of bladder, ii. 461 
Exudates, i. 24 
Eye, surgical affections of, ii. 701 
Eyeball, inflammation of, ii. 733 
Eyelids, diseases of, ii. 701, 704 
Eves, muscles of, external, affections of, ii. 
747 
FACE, diseases and injuries of, ii. 202 
Fallopian tubes, inflammation of, ii. 558 
Farcy, i. 149 
Fasciae, i. 487 
Fat-embolism, i. 40 
Fecal fistula, ii. 368 
Fell’s apparatus for forced respiration, i. 274 
Felon, i. 506 
Femoral artery, aneurism of, i. 582 
ligation of common, ii. 151 
Femur, fracture of, i. 729 
Fever, stages of, i. 117 
urethral, i. 273 
Fibroma, i. 411 
Fibrous union in bone, i. 361 
Fibula, dislocation of, i. 774 
fracture of, i. 746 
Pott’s fracture of, i. 746 
Filaria Bancroft!, i. 524 
Medinensis, i. 476 
sanguinis hominis, i. 460, 524 
Fingers, amputation of, ii. 599 
Fistula, i. 86 
fecal, ii. 368 
Flat-foot, ii. 658 
Fleischl’s haemometer, i. 49 
Foetal rickets, i. 673 
Folliculitis, i. 218 
Foot, amputation of, ii. 607 
arch of, affections of, ii. 657 
dislocation of, i. 775, 776 
fracture of, i. 748 
Foot, osteoplastic excision of, i. 644 
pronated, ii. 657 
Forced respiration, i. 274, 275 
Forearm, fracture of, i. 720 
Foreign bodies in wounds, i. 380 
Fractures, i. 690 
Framboesia, ii. 209 
Frost-bites, i. 485 
Furuncle, i. 82, 447 
GALL-BLADDER, rupture of, ii. 341 
Gall-stones, ii. 402 
Ganglion, i. 509 
Gangrene, i. 102, 154 
dry, i. 107 
following frost-bite, i. 486 
Gartner’s duct, cyst of, i. 393 
Gas phlegmons, i. 154 
Gasserian ganglion, removal of, ii. 122 
Gastro-enterostomy, ii. 354 
Gastrorrhaphy, ii. 355 
Gastrostomy, ii. 350 
Gastrotomy, ii. 350 
Genito-urinary tract, surgery of, ii. 457 
Genu valgum, ii. 648 
varum, ii. 645 
Gingivitis, ii. 327 
Girdner’s telephone probe, i. 332 
I Glanders, i. 149 
Glaucoma, ii. 729 
Gleet, i. 225 
Glioma, i. 409 
j Glossitis, acute parenchymatous, ii. 320 
Goitre, ii. 244 
Gonococcus, i. 73, 214 
{ Gonorrhoea, i. 214 
Gouty synovitis, i. 598 
Granulation tissue, i. 93 
Green-stick fracture, i. 690, 726 
Guinea-worm, i. 476 
Gumma, i. 202 
Gunshot wounds, i. 329 
penetrating, of abdomen, ii. 342, 344 
H-EMATOGELE, cystic degeneration of, 
i. 397 
| Hsematokrit, i. 47 
I hematoma of bursae, i. 511 
Haemoglobin, i. 51 
Haemothorax, ii. 267, 286 
Hallux valgus, ii. 671 
Hand, amputation of, ii. 601 
fracture of, i. 726 
Ilare-lip, ii. 220 
Head, gunshot wounds of, i. 338 
injuries and diseases of, ii. 17 
injuries of, previous and during birth, ii. 
24 
Heart, gunshot wounds of, i. 345 
surgical diseases and injuries of, ii. 126 
wounds and injuries of, ii. 271 
Hemorrhage in bullet wounds, i. 332 
from catheterization, i. 272 
control of, i. 257, 258 
Hereditary syphilis, i. 207 
Heredity as a cause for tumors, i. 387 GENERAL INDEX. 
799 
Hermaphrodism, ii. 459 
Hernia, ii. 407 
femoral, ii. 415 
inguinal, ii. 412 
of muscles, i. 325 
treatment, operative, for radical cure, ii. 
423 
Herniotomy, ii. 421 
Heteroplasty, ii. 686 
Hip, dislocation of, i. 768 
congenital, ii. 640 
excision of, i. 637 
synovitis of, i. 596 
Hip-joint, disarticulation of, ii. 620 
Hodgen’s splint, i. 736 
Hodgkin’s disease, i. 532 
Hordeolum, ii. 702 
Housemaid’s knee, i. 512 
Humerus, epiphyseal separation of, i. 716 
fracture of, i. 715 
■Hutchinson’s teeth, i. 209 
Hydatid disease of bone, i. 672 
of Morgagni, i. 393 
Hydrarthrosis, i. 601 
Hydrocele, ii. 510 
Hydrocephalus, ii. 64 
in rickets, i. 237 
Hydroma, i. 173, 504, 511 
Hydronephrosis, ii. 500 
Hydrophobia, i. 146 
Hydrops tuberculosis, i. 617 
Hydrothorax, ii. 282 
Hyoid bone, dislocation of, ii. 240 
fracture of, i. 710 
Hyperemia, i. 17 
Hyperesthesia in pyemia, i. 128 
Hyperostoses, i. 684 
Hyperplasia from occlusion of lymph-chan- 
nels, i. 521 
Hypertrophy and atrophy, difference be- 
tween, i. 27 
of prostate, ii. 481 
Hypospadias, ii. 458 
Hysterectomy, ii. 546 
Hysterical joints, i. 608 
JCHORRHiEMIA, i. 125 
1. Idiopathic muscular spasm, i. 145 
Ignipuncture, i. 267 
in bone tuberculosis, i. 663 
Iliac artery, aneurism of, i. 582 
ligation of common, ii. 148 
Imbecility, surgical treatment of, ii. 67 
Immersion in pyemia, i. 129 
in shock, i. 232 
Immunity, i. 60, 68 
Implantation dermoids, i. 400 
Impotence, ii. 515 
Incisions in palmar abscess, i. 509 
Indican in relation to intestinal putrefac- 
tion, i. 116 
Indicanuria, i. 116 
Infection, auto-, i. 109 
paths of, within cranium, ii. 51 
Infections of bone, consequences of, i. 657 
Inflammation, i. 53 
as a cause for tumors, i. 388 
Influenza, secondary infection in, i. 241 
Infusion, i. 270 
Injury and l-epair, i. 319 
Innominate artery, aneurism of, i. 577 
Inoculation of cancer, i. 389 
, | Insemination, disorders of, ii. 515 
j Instillation of deep urethra, i. 228 
j Instruments, sterilization of, i. 372 
Intercondyloid fracture of femur, i. 733 
Interscapulo-thoraeic amputation, ii. 606 
Intestinal antiseptics in septicaemia, i. 125 
intoxication, i. 113 
Intestines, obstruction of, acute, ii, 356 
chronic, ii. 364 
surgery of, ii. 356 
suture of, ii. 369 
Intoxication, auto-, i. 109 
Intoxications, acute, i. 251 
Intracapsular fracture of neck of femur, i. 
729 
Intracranial defective development, ii. 67 
tumors, ii. 71 
Intraocular tumors, ii. 734 
Intubation of larynx, ii. 171 
Intussusception, ii. 358 
of bowel, ii. 440 
Inunction, mercurial, in syphilis, i. 212 
Involucrum, i. 670 
Iodine, toxic effect of, i. 254 
Iodoform in tubercular joints, i. 621, 622 
in tuberculosis, i. 166 
poisoning, i. 378 
Iris, inflammation of, ii. 727 
Iritis, ii. 727 
Irritation as a cause for tumors, i. 387 
Ischium, fracture of, i. 729 
JACKET CANCER, i. 433 
Jaw, dislocation of, i. 753 
fracture of, i. 707 
Jaws and teeth, surgical diseases and inju- 
ries of, ii. 325 
Jejunostomy, ii. 375 
Joints and joint structures, injuries and dis- 
eases of, i. 584 
aspiration of, i. 263 
fractures into, repair of, i. 701 
implication of, in dysentery, i. 240 
operations on, i. 629 
KARYOKINESIS, i. 55 
Keloid, i. 412, 458 
Kidney, diseases of, ii. 495 
injuries of, ii. 466 
tuberculosis of, i. 174 
Knee, disarticulation of, ii. 616 
dislocation of, i. 773 
excision of, i. 640 
synovitis of, i. 596 
Knock-knee, ii. 648 
Knots, i. 268 
Kobelt’s tubules, cyst of, i. 393 
Kocher’s method of reducing dislocations 
of shoulder, i. 759 
dorsal dislocations of hip, i. 771 
forward dislocations of hip, i. 771 
j Koch’s bacillus, i. 160 800 
G ENERA L INDEX. 
Koch’s tuberculin, i. 115 
Kyphosis due to rickets, i. 237 
IABORDE’S method of rhythmical trac- 
J tion of tongue, i. 302 
Lacerations, i. 319 
Lachrymal apparatus, diseases of, ii. 723 
bone, fracture of, i. 706 
Laryngectomy, ii. 179 
Laryngoceles, ii. 235 
Larynx, injuries of, ii. 159 
intubation of, ii. 171 
surgical injuries and diseases of, ii. 
158 
Lateral curvature of spine, ii. 110 
Leg, amputation of, ii. 612 
Leontiasis, i. 682; ii. 23 
Lepra, i. 179 
Leprosy, i. 179 
Leucocytes in repair, i. 350 
in Hodgkin’s disease, i. 534 
properties of, i. 49 
Leucokeratosis, i. 206, 207 
Leucomaine, i. 115 
Ligament, Y-, i. 769 
Ligatures, sterilization of, i. 376 
Lipoma, i. 410 
Li ps, surgery of, ii. 219, 223, 317 
Listerism, i. 362 
Lithotomy, ii. 490 
Liver, surgery of, ii. 341 
surgical diseases of, ii. 341 
Lock finger, i. 502 
Lockjaw, i. 138 
Lues Venerea, i. 182 
Lumbar abscess, i. 660 
Lumpy-jaw, i. 156, 158 
Lung, surgery of, ii. 268 
Lupus, i. 168, 470 
Luschka’s tonsil, i. 397, 400 
gland, i. 397, 400 
Lymphadenitis, i. 529 
Lymphangeiectases, i. 457 
Lymphangeioma, i. 419 
Lymphangitis due to filaria sanguinis hom- 
inis, i. 545 
due to gonorrhoeal infection, i. 220 
in septicaemia, i. 122 
Lymphatic vessels and nodes, injuries and 
diseases of, i. 518 
Lymphatics, injury to, i. 323 
Lymph-nodes, tuberculosis of, i. 169 
Lymphoedema, i. 522 
Lymphorrhagia, i. 522 
Lympho-sarcoma, i. 532 
Lymph-scrotum, i. 528 
Lyssa, i. 146 
Lyssophobia, i. 148 
MACROCHEILIA, i. 420,522; ii. 220,318 
Macrodactylia, i. 522 
Macroglossia, i. 420, 522; ii. 322 
Macromelia, i. 522 
Macropodia, i. 522 
Macrostoma, ii. 220 
Malar bone, fracture of, i. 707 
Malignant degeneration of scar, i. 97 
Malignant growths, differential diagnosis 
from benign, i. 440 
oedema, i. 154 
pustule, i. 151 
Mallein, i. 151 
Mammary gland, tuberculosis of, i. 175 
Mania due to drugs, i. 253, 254 
post-operative, i. 252 
Marie’s disease, i. 680 
j Mastodynia, ii. 573 
| Mastoid, operation, ii. 760 
Maxilla, fractures of, i. 706, 707 
1 Measles, secondary infection in, i. 241 
Meckel’s ganglion, removal of, ii. 122 
Mediastinitis, ii. 277 
Mediastinum, surgery of, ii. 267, 295 
Melanoma, i. 406 
Membrana tympani, rupture of, ii. 756 
Meningitis, ii. 57, 66 
Mercurial necrosis, i. 667 
Mercury in syphilis, i. 210 
toxic effect of, i. 255 
Mesarteritis, i. 552 
Mesentery, diseases of, ii. 392 
Metacarpal bones, fracture of, i. 726 
Metacarpo-phalangeal dislocations, i. 765 
Metacarpus, excision of, i. 636 
Metastatic abscesses, i. 126 
Metatarsal bones, fracture of, i. 748 
Metatarsalgia, ii. 672 
Micro-organisms in bone affections, i. 648 
in dental caries, i. 245 
in wounds, manner of access, i. 320 
sources in wound-infection, i. 362 
Microstoma, ii. 220 
Miliary tubercle, i. 161 
Milium, i. 444 
Milking of seminal vesicles, ii. 480 
Milzbrand, i. 151 
j Minor surgery, i. 268 
Mixed infection complicating exanthemata, 
i. 239 et seq. 
Moles, i. 453 
i Molluscum fibrosum, i. 412, 462 
! Morbus coxae senilis, i. 605 
Mortality after amputation, ii. 623 
Mouth, bacteria of, ii. 312 
surgical diseases and injuries of, ii. 311 
Muscles, hernia of, i. 325 
injuries of, i. 325 
tendons, tendon sheaths, fasciae, and bursae, 
i. 487 _ _ 
| Mustard, germicidal effect of, i. 365, 366 
! Myo-fibromata of uterus, ii. 542 
Myoma, i. 417 
Myositis, i. 494 
Myotomy, i. 514 
Myxoma, i. 416 
NJEVUS, h 418 
telangeiectasis, i. 454 
Naphthalin, toxic effect of, i. 254 
Nasal cavities, injuries of, ii. 199 
Neck, cysts of, i. 393 
gunshot wounds of, i. 342 
Necrosis, i. 102, 667 
Nephralgia, ii. 505 GENERAL INDEX. 
801 
Nephrectomy, ii. 514 
Nephritis following burns, i. 481 
suppurative gonorrhoeal, i. 220 
Nephrotomy, ii. 502, 513 
Nerves, injuries of, i. 323 
surgery of, ii. 118 
tumors of, ii. 124 
Neuralgia, ii. 120 
intercostal, ii. 272 
operations on fifth nerve for relief, ii. 214 
Neuroma, i. 421 
Neuropathic diseases of joints, i. 606 
Nipple and areola, diseases of, ii. 565 
Paget’s disease of, i. 466 
Nitrous-oxide gas, i. 292 
Noma, i. 104; ii. 317 
Nose, accessory sinuses to, diseases of, ii. 196 
fracture of, i. 704 
surgery of, ii. 216 
Nuhn’s gland, cyst of, i. 395 
Nystagmus, ii. 748 
Odontoma, i. 415 
(Edema, lymph, i. 522 
(Esophagectomy, ii. 310 
CEsophagismus, ii. 306 
(Esophagotomy, external, ii. 306 
(Esophagus, surgical injuries and diseases 
of, ii. 301 
Olecranon process, fracture of, i. 720 
Omentum, surgery of, ii. 391 
Onychia, i. 477 
Oophorectomy for uterine fibroids, ii. 550 
Operations on joints, i. 629 
Ophthalmia, purulent, ii. 712 
sympathetic, ii. 730 
Opisthotonos, i. 141 
Orbit, injuries of, ii. 736 
Orchitis, i. 220; ii. 507 
Osseous system, surgical diseases of, i. 647 
Osteo-arthritis, i. 603 
Osteo-artln-opathie hvpertrophiante pneu- 
mique, i. 680 
Osteochondritis syphiliticus, i. 209 
Osteoclasis, ii. 647 
Osteoma, i. 414 
Osteomalacia, i. 675 
Osteomyelitis, i. 648 
Osteoporosis, i. 658, 679 
Osteopsathyrosis, i. 678 
Osteosarcoma, i. 685 
Osteosclerosis, i. 658 
Osteotomy, ii. 648, 650 
Ostitis deformans, i. 679 
Ovary, cysts of, ii. 552 
surgery of, ii. 552 
PACHYDERMATOCELE, i. 412 
Paget’s disease, i. 466 
of bones, i. 679 
of nipple, ii. 565 
Pain, i. 312 
Palmar abscess, i. 508 
Panarthritis, i. 615 
Pancreas, surgery of, ii. 393 
surgical diseases of, ii. 393 
Panophthalmitis, ii. 733 
Vol. II.—51 
Papilloma, i. 423 
Papular syphilide, i. 198 
Paracentesis, i. 283 
Parametrium, acute inflammatory processes 
of, ii. 556 
Paraphimosis, gonorrheal, i. 223 
Parasitic theory of tumor-formation, i. 389 
Paronychia, i. 478, 505 
Parotid gland, surgery of, ii. 247 
Paroophoron, cysts of, i. 393 
Parovarian cysts, i. 393 
Patella, dislocation of, i. 773 
fracture of, i. 740 
Pelvis, fracture of, i. 727 
Pemphigus syphiliticus, i. 208 
Penis, congenital malformations of, ii. 457 
gunshot wounds of, i. 348 
injuries of, ii. 462 
Perforating ulcer, i. 477 
Pericarditis, surgical treatment of, ii. 131- 
133 
Pericardium, injuries and surgical diseases 
of, ii. 126, 270 
wounds and injuries of, ii. 127, 270 
Perimetrium, inflammation of, ii. 557 
Perineal section, ii. 512 
Perineorrhaphy, ii. 528 
Perinephritis, ii. 504 
Perineum, ii. 526 
Periostitis, i. 655 
Peritoneum, surgery of, ii. 383 
tuberculosis of, i. 175 
Peritonitis, acute, ii. 383 
following burns, i. 481 
Peri-urethral inflammation, i. 218 
Pes cavus, ii. 669 
planus, ii. 658 
Phagocytosis, i. 50, 51, 57 
Pharynx, surgery of, ii. 182 
Phimosis, ii. 457 
gonorrhoeal, i. 223 
Phlebitis, i. 537 
Phlegmon, i. 79 
Phosphorus-necrosis, i. 668 
Piles, ii. 433 
Pituitary body in acromegaly, i. 682 
Pleura, injuries to, ii. 267 
Pleurisy following burns, i. 481 
Pleurosthotonos, i. 141 
Pneumonia, surgical sequelae of, i. 240 
Pneumotomy, ii. 279, 296 
Popliteal artery, aneurism of, i. 582 
Port-wine mark. i. 454 
Post-gonorrhoeal arthritis, i. 220 
synovitis, i. 598 
Pott’s disease of spine, ii. 94 
fracture, i. 745 
Pregnancy, ectopic, ii. 559 
Prepuce, congenital malformations, ii. 457 
oedema of, i. 220 
Progressive muscular atrophy, i. 498 
Prostate, diseases of, ii. 479 et seq. 
milking in gleet, i. 227, 228 
Prostatectomy, ii. 485 
Prostatitis, i. 219 
chronic, ii. 480 
Protozoa, i. 77 802 
GENERAL INDEX. 
Psammomata, i. 425 
Pseudo-leukaemia, i. 532 
Pseudo-muscular hypertrophy, i. 499 
Psoas abscess, i. 660 
Psorosperms in tumors, i. 389 
Pterygium, ii. 715 
Ptomaines, i. 115 
Ptosis, ii. 705 
Puerperal mania, i. 252 
Puruloid, i. 362 
Pus, i. 78, 80 
Pyaemia, i. 125 
Pyelitis, ii. 495 
due to gonorrhoeal infection, i. 220 
Pyelo-nephritis, ii. 495 
Pylorectomy, ii. 353 
Pyloroplasty, ii. 352 
Pylorus, operations on, incision for, ii. 350 
surgery of, ii. 347 
Pyogenic bacteria in bladder, ii. 487 
Pyoid material, source of, i. 93 
Pyoktanin in treatment of cancer, i. 443 
Pyonephrosis, ii. 497 
Pyophylactic membrane, i. 88, 164 
Pyosalpinx, ii. 559 
Rabies, i. 146 
Rachitis, i. 235, 674 
Radical cure of hernia, ii. 423 
Radiography, ii. 764 
Radius, i. 722 
dislocation of, i. 763 
fracture of, i. 722 
Ranula, i. 395; ii. 322 
Rathke’s pouch, i. 396 
Rauschbrand, i. 156 
Raynaud’s disease, i. 103 
Rectocele, ii. 538 
Rectum, gonorrhoea of, i. 217 
Recurrence of hernia after radical cure, ii, 
428 
Regeneration of tissue, i. 356 
Repair, i. 350 
Resection of joints, i. 629 
Rheumatism, chronic articular, i. 602 
Rheumatoid arthritis, i. 603 
Rhinoplasty, ii. 218 
Rhinoscleroma, i. 475; ii. 194, 218 
Rhus toxicodendron, poisoning by, i. 249 
Ribs, dislocation of, i. 754 
fracture of, i. 710 
Rice bodies, i. 504 
Rickets, i. 235 
Rider’s bone, i. 494 
Rodent ulcer, i. 463, 478 
Rontgen rays in surgery, application of, ii, 
764 
Roseola syphilitica, i. 198 
Rubefacients, i. 264 
Rupial syphilide, i. 199 
O ACRAL cysts, ii. 84 
lU Sacrum, fracture of, i. 728 
Salpingitis, ii. 558 
Sapraemia, i. 119 
Sarcoma of bone, i. 685 
! Sarcoma of cutis, i. 468 
differential diagnosis from carcinoma, i. 
441 
melanotic, i. 468 
Scab, healing under, i. 355 
Scalds, i. 479 
Scalp surgery, diseases of, ii. 17 
Scapula, fracture of, i. 714 
Scar, hypertrophied, i. 458, 459 
Scarlatina following operations, i. 119 
Scars, degenerations in, after burns, i. 482 
Scoliosis, ii. 110, 258, 629 
Scrofuloderma, i. 472 
Scurvy, i. 234 
Secondary infection in syphilis, i. 184 
Semen, involuntary discharge of, ii. 518 
Semilunar cartilages, dislocation, i. 610, 774 
\ Senile fragility of bones, i. 679 
Sepsis, i. 537 
following burns, i. 481 
Septicaemia, i. 122 
Septic enteritis, i. 113 
infection, i. 85 
suppository as a cause of sapraemia, i. 120 
Sequestrum formation, i. 669 
Serum-therapy in cancer, i. 443 
in snake-bite, i. 248 
Seton, i. 266 
Shock, i. 230 
Shoulder, disarticulation of, general con- 
siderations, ii. 604 
excision of, i. 631 
surgical treatment of old dislocations, i. 
761 
Shoulder-joint, dislocation of, i. 755 
Sialo-ductilitis, ii. 229 
Sinew, weeping, i. 509 
Sinus, i. 86 
phlebitis, ii. 56 
thrombosis, ii. 55 
Sinuses, accessorv to nasal cavities, diseases 
of, ii. 196 
Skiagraphy, ii. 763 
Skin diseases, surgical, i. 444 
inoculation through unbroken skin, i. 518 
regeneration of, i. 356 
syphilis of, i. 196 
tuberculosis of, i.'470 
Skin-grafting, i. 277 
Skull, diseases of, non-inflammatory, ii. 20 
fractures of, ii. 28 
surgical anatomy of, ii. 25 
Snake-bite, i. 247 
Sources of infection, i. 64 
Spermatic cord, diseases of, ii. 508 
Spermatocele, ii. 508 
Spermatorrhoea, ii. 518 
Sphacelus, i. 102 
Spinal column, gunshot wounds of, i. 343 
cord, tumors of, ii. 117 
Spine, curvature, lateral, ii. 629 
injuries and surgical diseases of, ii. 80 
operations on, ii. 112, 113,114 
surgical diagnosis and examination of, i. 
310 
Spleen, surgical diseases of, ii. 396 
Splenic fever, i. 151 GENERAL INDEX. 
803 
Splenectomy, ii. 398 
Splenopexis, ii. 399 
Spondylitis, ii. 94 
Sponges, sterilization of, i. 376 
Spontaneous fractures, i, 677 
Sporozoa in tumors, i. 389 
Squint, ii. 747 
Staphylorrhaphy, ii. 314, 336 
Steatoma, i. 446 
Stenoses of intestine, ii. 367 
Stercorsemia, i. 113 
Sterility, ii. 517 
Sterilization, i. 364 
Sterno-mastoid, hsematoma of, i. 490 
Sternum, dislocation of, i. 754 
fracture of, i. 711 
Stitch abscesses, bacteria of, i. 64 
Stomach, fistube of, ii. 347 
operations on, ii. 350 
surgery of, ii. 344 
Stomatitis, ii. 316 
Stone in bladder, ii. 488 
in kidney, ii. 498 
Strabismus, ii. 747 
Strength of bone, i. 694 
Stricture of urethra, ii. 472 
of pylorus, ii. 349 
Strumitis, ii. 246 
Stye, ii. 702 
Styptics, i. 259 
Subclavian artery, ligation of, ii. 141 
Subcutaneous injuries, !. 319 
Subphrenic abscess, ii. 274, 346 
Suppuration, i. 78 
Supracondyloid fracture of humerus, i. 718 
of femur, i. 733 
Suprapubic cystotomy, ii. 513 
Surgical case, how to report, i. 316 
diseases of skin, i. 444 
fevers, the, i. 117 
pathology of the blood, i. 32 
sequel* of diseases, i. 239 
Suture of intestine, ii. 369 
Sutures, classification of; i. 380 
methods of application, i. 269 
sterilization of, i. 376 
Symptomatic charbon, i. 156 
Syndactylism, i. 487 
Synovial tuberculosis, i. 616 
Synovitis, i.»593 
Syphilis, i. 182 
of bone, i. 664 
of muscles, i. 496 
Syringomyelia, ii. 84 
TMNIA ECHINOCOCCUS, i. 397 
Tailor’s ankle, i. 513 
Talipes equinus, ii. 665 
equino-varus, congenital, ii. 650 
varus, ii. 667 
calcaneus, ii. 667 
Teeth, extraction of, i. 278 
surgical diseases of, ii. 326 
wiring of, in fractures of jaw, i. 709 
Telangeiectasis of skin, i. 454 
Tendon-grafting, ii. 668 
Tendon-sheath, regeneration of, i. 356 
j Tendon-sheaths, i. 487 
| Tendons, i. 487 
injuries of, i. 326 
regeneration of, i. 356 
Tenotomy, i. 514 
Teratomata, i. 402 
Tertiary syphilis, i. 201 
Testes, gunshot wounds in, i. 349 
| Testicle, congenital malformations of, ii. 461 
diseases of, ii. 506 
suppuration of, i. 224 
tuberculosis of, i. 174 
Tetanella, i. 145 
Tetanus, i. 138 
Thecitis, i. 503 
Thigh, amputation of, ii. 617 
i fracture of, i. 729 
Thoracentesis, ii. 282, 2S4 
Thoracic duct, wounds of, ii. 255, 270 
Thoracoplasty, ii. 288 
Thoracotomy, ii. 286 
Thorax, gunshot wounds of, i. 344 
walls of, diseases of, ii. 272 
Thrombi, metamorphosis of, i. 35 
Thrombo-arteritis, i. 126 
Thrombo-phlebitis, i. 37 
Thrombosis, i. 34 
Thumb, excision of, i. 636 
Thyroid body, surgery of, ii. 242 
duct, i. 401 
Thyroids, accessory, i. 400 
Thyrotomy, ii. 169 
Tibia, fracture of, i. 742 
Tissues, regeneration of, i. 356 
Toe-nail, ingrown, i. 276 
Toes, amputation of, ii. 607 
Tongue, gumma of, i. 207 
rhythmical traction of, i. 302 
surgical diseases and injuries of, ii. 318 
Tongue-tie, ii. 319 
Tonsils, surgery of, ii. 188 
Tonsillotomy, ii. 189 
Torticollis, ii. 252, 626 
Tourniquets, i. 258 
Toxalbumens, i. 115 
Toxic antiseptics, i. 253 
Toxicity of urine, i. 110, 112 
Trachea, surgery of, ii. 159, 179 
wounds of, ii. 159 
Tracheal tugging in aneurism, i. 577 
Tracheoceles, ii. 235 
Tracheoma, ii. 714 
Tracheotomy, ii. 165 
Traction in reducing dislocations of shoul- 
der, i. 760 
Trauma as a cause for tumors, i. 387 
Traumatic fever, i. 118 
mania, i. 252 
Transfusion of blood, i. 270 
Trephining, ii. 74 
Trichina spiralis, i. 514 
Trichinosis, i. 514 
Trigger-finger, i. 502 
Trismus, i. 138 
Trophoneurotic diseases of bones, i. 673 
Trusses for hernia, ii. 420 
Tubercular arthritis, i. 612 804 
GENERAL INDEX. 
Tuberculin, i. 178 
Tuberculosis, i. 160 
of bones, i. 170, 171, 658 
bursal, i. 173 
cold abscesses in, i. 166 
cutis, i. 471 
degenerative changes in, i. 162 
diagnosis of, i. 176 
differential diagnosis from epithelioma, i. 
441 
followed by mixed infection, i. 241 
fungous granulation in, i. 167 
of genito-urinary tract, ii. 468 
giant cells in, i. 161 
gummata in, i. 167, 168 
kidneys, ureter-, and bladder, i. 174 
lupus, i. 168 
of lymph-nodes, i. 530 
method of healing, i. 162 
miliary tubercle in, i. 161 
of mucous membranes, i. 168 
of muscles, i. 497 
of omentum, ii. 392 
ovary, i. 174 
paths of infection in, i. 175 
of skin, i. 168, 470 
of spine, ii. 94 
of tendon-sheath, i. 173 
of testicle, i. 174 
Tubes, Fallopian, inflammation of, ii. 558 
Tumors, i. 385, 683 
intraocular, ii. 734 
Tympanum, acute inflammation of, ii. 758 
Typhoid, secondary infection in, i. 242 
ULCER and ulceration, i. 89 
varicose, treatment, i. 543 
Ulna, dislocation of, i. 763 
fracture of, i, 720 
Unna’s paste, i. 451 
Unreduced dislocations, pathology of, i. 751 
Uranoplasty, ii. 315, 333 
Urea in auto-intoxication, i. Ill 
Ureter, tuberculosis of, i. 174 
Ureteritis, due to gonorrhoeal infection, i. 
220 
Urethra, congenital malformations of, ii. 457 
diseases of, ii. 471 
injuries of, ii. 463 
Urethral fever, i. 273 
or urinary fever, ii. 478 
Urethritis, deep gonorrhoeal, i. 219 
Urethrometer, i. 226 ; ii. 474 
Urethroscope, i. 226 
Urethrotome, i. 227 
Urethrotomy, i. 629; ii. 512 
external, ii. 512 
Urinary antiseptics, ii. 479 
fever, ii. 478 
infiltration, following fracture of pelvis, 
i. 728 
Urine, toxicity of, i. 112 
Uterus, surgery of, ii. 538 
Uvula, malformations of, ii. 180 
VAGINA, malformations of, ii. 522 
Varicocele, ii. 508 
Varicose veins, i. 538 
Varix, lymph, i. 521 
aneurismal, i. 566 
Vasectomy for prostatic enlargement, ii. 485 
Veins, i. 536 
excision of, i. 541 
injury of, i. 323 
surgical injuries and diseases of, i. 536 
varicose, of lower extremity, i. 153, 539 
Venereal ulcer, ii. 519 
Venesection, i. 260 
Venous nsevus, i. 544 
Vermiform appendix, ii. 375 
Verruca, i. 451 
Vertebral acute osteomyelitis, ii. 110 
artery, aneurism of, i. 581 
Vesicants, i. 265 
Vesiculitis, treatment of, i. 224 
Vessels, injuries of, 321 
lymphatic, injuries of, i. 323 
Viscera, gunshot wounds of, i. 345 
injury to, following blows upon abdominal 
wall, ii. 339 
Volvulus, ii. 360 
Vulva, inflammation about, ii. 523 
surgery of, ii. 523 
WARTS, i. 423, 451 
T V Wax, in treatment of bone disease, i. 
671 
| Webbed fingers, i. 487 
| Weeping sinew, i. 509 
Wen, i. 430 
Whitlow, i. 506 
! Wiring bone fragments, i. 707, 709, 710 
in compound fractures, i. 702 
Wolffian body, cysts of, i. 392, 393 
Wool-sorter’s disease, i. 151 
Wound infection in joints, i. 588 
Wounds of bladder, i. 348 
gunshot, i. 327 
of penis, i. 348 
treatment of, i. 363 
Wrist, dislocation of, i. 764 
excision of, i. 634 
fracture of, i. 726 
Writer’s cramp, i. 493 
Wry neck, ii. 253, 624 
XIPHOID CARTILAGE, fracture of, i. 
712 
! X-rays in gunshot wounds, i. 331 
in surgery, ii. 763 
yAWS, ii. 209 
jL Y-ligament, its influence on dislocations 
and their reduction, i. 769 
ARCII, fracture of, i. 707